Stratification of surgical site infection by operative factors and comparison of infection rates after hernia repair

Polypropylene vs. stainless-steel wire suture: short-term recurrence rate after shouldice primary inguinal hernia repair, a non-inferior analysis among 1120 patients. A case-control study

INTRODUCTION

Polypropylene material is commonly used for posterior wall reconstruction in hernia repair, in contrast with the classically described stainless-steel wire used at Shouldice Hospital. This study was conducted to evaluate possible differences in Shouldice Repair outcomes using polypropylene or stainless-steel wire sutures.

METHODS

A prospective follow-up of consecutive patients who underwent elective unilateral Shouldice primary inguinal hernia repair at Shouldice Hospital between December 6, 2021, and September 1, 2022, was conducted. Data was collected from follow-up telephone calls as well as manually reviewing patient's charts. The primary objective was to determine whether the use of polypropylene was non-inferior to the use of stainless-steel wire, regarding the recurrence rate reported by the patients with a minimum follow-up of 1 year after Shouldice primary inguinal hernia repair.

RESULTS

A total of 1120 patients were contacted by telephone (polypropylene: 560; stainless-steel wire: 560). The median follow-up period was 16 months (interquartile range: 15-18). In 22 (1.96%) cases a surgical site infection was diagnosed. There was a total of 18 recurrences reported by the patients (1.6%). There was no statistical difference between the groups (polypropylene: 7 (1.25%) vs. stainless steel wire: 11 (1.96%), p > 0.05) for the recurrence rate.

CONCLUSION

The use of polypropylene is non-inferior to the use of stainless-steel wire regarding recurrence rate at a median follow-up period of 16 months after elective unilateral Shouldice primary inguinal hernia repair. This finding may encourage other centers where stainless-steel wire is not easily available to perform the Shouldice Repair.

Comparing Robot-Assisted and Laparoscopic Inguinal Hernia Repair: A Systematic Review and Meta-Analysis

Inguinal hernia repair is a common surgical intervention. Advancements in minimally invasive techniques, specifically laparoscopic (LR) and robot-assisted (RR) approaches, have reshaped the landscape of surgical options. This meta-analysis aimed to systematically assess and compare the effectiveness and safety of laparoscopic and robot-assisted inguinal hernia repair through a comprehensive review of the literature. A systematic search of databases was conducted to identify relevant studies published up to November 30, 2023. Fifteen studies, encompassing a total of 64,568 participants, met the inclusion criteria. Pooled estimates for key outcomes, including duration of operation, overall complications, and surgical site infection (SSI), were calculated using random-effects models. This meta-analysis revealed a statistically significant difference in the duration of surgery, favoring laparoscopic repair over robot-assisted techniques (mean difference: 26.85 minutes, 95% CI (1.16, 52.54)). Overall complications did not significantly differ between the two approaches (odds ratio: 1.54, 95% CI (0.83, 2.85)). However, a significantly greater risk of SSI was identified for robot-assisted procedures (odds ratio: 3.32, 95% CI (2.63, 4.19)). This meta-analysis provides insights into the comparative effectiveness of laparoscopic and robot-assisted inguinal hernia repair. While laparoscopy has shorter operative times and comparable overall complication rates, the increased risk of SSI during robot-assisted procedures necessitates careful consideration in clinical decision-making. Surgeons and healthcare providers should weigh these findings according to patient characteristics, emphasizing a personalized approach to surgical decision-making. The evolving landscape of inguinal hernia repair warrants ongoing research to refine techniques and optimize outcomes for the benefit of patients undergoing these procedures.

Does a Presurgical Antisepsis Protocol Decrease Surgical Site Infections in Young Children?

National standards for surgical site infection (SSI) prevention for children remain elusive. Our institution developed a presurgical antisepsis protocol that included the three components of chlorhexidine gluconate bathing wipes, chlorhexidine gluconate oral rinse, and povidone-iodine nasal swab. This retrospective cohort study examined data from electronic health records to compare SSI rates before and after protocol implementation. We included children aged 2 through 11 years undergoing any surgical procedure with the use of an incision in the OR (N = 1,356). We did not find any difference in the occurrence of SSI before and after the protocol was implemented. Logistic regression showed that an infection present at the time of surgery was the only significant predictor of an SSI. The implementation of a presurgical antisepsis protocol was not associated with SSI rate reduction in this pediatric cohort.

Surgical aspects and early morbidity of patients undergoing open recurrent inguinal hernia repair

PURPOSE

This study aims to characterize the patterns of recurrence associated with specific types of primary inguinal hernia repair techniques used for and their respective correlations with early morbidity, in patients undergoing open repair for their first hernia recurrence.

METHODS

After ethics approval was obtained, a retrospective review of charts from patients who underwent open surgery for repair of a first recurrence after a previous inguinal hernia repair during 2013-2017 was completed. Statistical analyses were performed and p-values < .05 are reported as statistically significant.

RESULTS

1393 patients underwent 1453 surgeries for recurrent inguinal hernias at this institution. Operations for recurrence were longer (61.9 ± 21.1 vs. 49.3 ± 11.9; p < .001), required more frequent intra-operative surgical consultation (1% vs. 0.2%; p < .001) and had a higher incidence of surgical-site infections (0.8% vs. 0.4%; p = .03) than primary inguinal hernia repairs. When comparing the patterns of recurrence among different techniques of primary repairs, patients undergoing laparoscopic hernia repair presented with a higher incidence of indirect recurrences. Reoperations after a Shouldice repair and open mesh repair represented markers for higher surgical difficulty in the recurrent operation (longer operative time, higher identification of heavy scarring, less nerve identification, and higher frequency of intra-operative consultation), but not higher rates of complications when compared with other techniques.

CONCLUSIONS

Open reoperations for inguinal hernia first recurrences are more complex, with noticeable differences according to the index operation, and associated with higher morbidity when compared with primary hernia repairs. This complexity varies according to the type of primary surgery, with a previous Shouldice repair and open hernia repair with mesh presenting higher surgical difficulties although this did not translate to higher incidence of early complications. This information may allow adequate allocation of surgeons with an expertise in recurrent hernias and choice of recurrent repair method (laparoscopic or open) based on the primary surgery.

Update of the international HerniaSurge guidelines for groin hernia management

BACKGROUND

Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias.

METHOD

A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary.

RESULTS

Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022.

CONCLUSION

The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

Do postoperative complications correlate to chronic pain following inguinal hernia repair? A prospective cohort study from the Swedish Hernia Register

PURPOSE

To analyse if postoperative complications constitute a predictor for the risk of developing long-term groin pain.

METHODS

Population-based prospective cohort study of 30,659 patients operated for inguinal hernia 2015-2017 included in the Swedish Hernia Register. Registered post-operative complications were categorised into hematomas, surgical site infections, seromas, urinary tract complications, and acute post-operative pain. A questionnaire enquiring about groin pain was distributed to all patients 1 year after surgery. Multivariable logistic regression analysis was used to find any association between postoperative complications and reported level of pain 1 year after surgery.

RESULTS

The response rate was 64.5%. In total 19,773 eligible participants responded to the questionnaire, whereof 73.4% had undergone open anterior mesh repair and 26.6% had undergone endo-laparoscopic mesh repair. Registered postoperative complications were: 750 hematomas (2.3%), 516 surgical site infections (1.6%), 395 seromas (1.2%), 1216 urinary tract complications (3.7%), and 520 hernia repairs with acute post-operative pain (1.6%). Among patients who had undergone open anterior mesh repair, an association between persistent pain and hematomas (OR 2.03, CI 1.30-3.18), surgical site infections (OR 2.18, CI 1.27-3.73) and acute post-operative pain (OR 7.46, CI 4.02-13.87) was seen. Analysis of patients with endo-laparoscopic repair showed an association between persistent pain and acute post-operative pain (OR 9.35, CI 3.18-27.48).

CONCLUSION

Acute postoperative pain was a strong predictor for persistent pain following both open anterior and endo-laparoscopic hernia repair. Surgical site infection and hematoma were predictors for persistent pain following open anterior hernia repair, although the rate of reported postoperative complications was low.

Effect of stapled versus layered skin closure on surgical site occurrences after abdominal wall reconstruction

BACKGROUND

The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure.

METHODS

A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized.

RESULTS

A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045).

CONCLUSION

Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

Analysis of risk factors for surgical site infection and postoperative recurrence following inguinal and femoral hernia surgery in adults

OBJECTIVE

We aimed to evaluate the causes of complications following surgery for inguinal and femoral hernia, using surgical site infection (SSI) and recurrence rate as indicators of outcomes to consider appropriate treatments.

METHODS

We retrospectively assessed the medical histories of 1,098 patients with adult inguinal and femoral hernias who underwent herniorrhaphy between July 2010 and March 2019. Using SSI and recurrence rate as indicators of outcomes, we statistically assessed the influence of preoperative and operative conditions on surgical outcomes.

RESULTS

The occurrence of postoperative SSI was significantly more frequent in patients who experienced a long surgical duration, excessive blood loss, and incarceration; underwent emergency surgery and bowel resection; and in whom no mesh sheet insertion was performed. There was no correlation between mesh use and SSI in cases that did not require emergency incarceration repair. For cases involving hernia incarceration, the use of a mesh sheet was avoided to prevent potential infection, which could explain the high incidence of SSI in cases where mesh was not used. The hernia may have recurred due to technical issues during the procedure, as well as failure to ligate the hernia sac.

CONCLUSIONS

Selecting the appropriate surgical method for hernia repair may reduce the incidence of SSI. If manual reduction of inguinal hernias is not possible, an appropriate surgical procedure should be determined based on laparoscopic findings in facilities where laparoscopic hernia surgeries are frequently performed. Moreover, in cases without infection and bowel resection, mesh use may be beneficial. Recurrence can be prevented by ligating the hernia sac during surgery and solving relevant technical problems.

Large ventral hernias: to drain… And what to drain… That is the question!

BACKGROUND

Drain placement is common practice in repair of ventral hernias, specifically complex hernias. There is little-to-no evidence for benefit of drains and best practice in-terms of number, position, duration of use and type of drains. This study investigates drain profile in open repair of large ventral hernias.

METHODS

A retrospective two-centres audit with data collected via electronic and paper-based medical records from the 1 February 2015 to 29 June 2020. All elective and emergency cases were included. Main outcomes included surgical site infection (SSI), seroma and hematoma formation.

RESULTS

A total of 186 patients included, out of those 128(68.5%) had drain placed. Drain placement had a higher incidence of SSI (20.3% in drain group and 15.5% in no drain group), however, drains were more likely to be placed in complex ventral hernias. Drain practice varied significantly between surgeons, however, there was a clear trend to higher SSI rates with longer duration of drain use (specifically longer than 5 days, p-value: 0.05) and higher drain output on removal (specifically higher than 150 ml/24 h, p-value 0.004), furthermore, prolonged use did not decrease risk of seroma formation. Drain position, number of drains and suction pressure did not affect seroma or SSI rates.

CONCLUSION

Our data suggests no clear benefits of drain usage in most ventral hernia repairs. Prolonged drain use led to higher risk of SSI and did not decrease rate of seroma formation. If used, we recommend use of short drain duration<5 days. Further RCTs to evaluate drain placement in large ventral hernias are needed.

Pediatric surgical site infection (SSI) following ambulatory surgery: Incidence, risk factors and patient outcomes

BACKGROUND

Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes.

METHODS

We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case-control methodology using multivariate backward logistical regression to assess risk-factor association with SSI.

RESULTS

In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37-3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32-12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0-48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6-9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9-315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage.

CONCLUSIONS

Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.

A Polymer-Biologic Hybrid Hernia Construct: Review of Data and Early Experiences

Surgical mesh reinforcement of the human abdominal wall has been found to reduce the chance of recurrence in hernia repairs. While traditionally polymer meshes have been used in hernia repair, alternative mesh options have been engineered to prevent the inflammatory foreign body response invoked by polymers. A reinforced tissue matrix (RTM) mesh has been developed by embedding a polymer within a decellularized extracellular matrix. This combination has been attributed to the recruitment of host cells, a pro-healing response, and attenuation of the foreign body response. This has been observed to lead to the regeneration of functional tissue within the repair site that is reinforced by the polymer to offload abdominal pressures over time. This manuscript presents the review of OviTex, an RTM, in several types of hernia repair. The authors have found that the use of RTM in hernia repair is effective in preventing foreign body response, promoting wound healing, and providing reinforcement to lower the risk of hernia recurrence.

Robotic abdominal wall repair: adoption and early outcomes in a large academic medical center

Robotic-assisted abdominal wall repair (RAWR) has seen an exponential adoption over the last 5 years. Skepticism surrounding the safety, efficacy, and cost continues to limit a more widespread adoption of the platform. We describe our initial experience of 312 patients undergoing RAWR at a large academic center. A retrospective review of all patients undergoing any RAWR from July 1, 2016 to March 18, 2020 was completed. Patient specific, operation specific, and 30-day outcomes specific data were collected. Univariate analysis and multivariate logistic regression were used to assess factors associated with 30-day complications. There was a steady adoption of RAWR over the study period. A total of 312 patient were included, 138 (44%) were abdominal wall repairs and 174 (56%) were inguinal repairs. The mean age of the cohort was 54.2 years (SD 16), 69% were males, and the mean BMI was 29 kg/m² (SD 4.8). There were two reported intraoperative events and nine operative conversions. 60 patients had at least one complication at 30-days. These include: 52 seromas, 4 hematomas, 2 surgical-site infections, 1 deep venous thrombus, and 1 recurrence at 30-days. BMI, type of hernia, and sex were not associated with complications at 30-days. The use of absorbable mesh, longer hospital stay, operative conversion, previous repair, and expert hernia surgeon were significant predictors of 30-day complications. Age, operative conversion, and previous repair were the only predictors of 30-day complications on multivariate regression. Our initial experience of 312 patients demonstrates the adoption and comparable short-term outcomes for a wide variety of robotic-assisted hernia repairs.

Preoperative opioid use and incidence of surgical site infection after repair of ventral and incisional hernias

BACKGROUND

Preoperative opioid use is a risk factor for complications after some surgical procedures. The purpose of this study was to investigate the influence of preoperative opiates on outcomes after ventral hernia repair.

METHODS

With institutional review board approval, we conducted a retrospective review of consecutive ventral hernia repair cases during a 4-y period.

RESULTS

A striking 48% of the total 234 patients met criteria for preoperative opioid use. Preoperative characteristics and operative details were similar between patient groups (preoperative opioid use versus no preoperative opioid use). Median duration of hospital stay trended toward an increase for opioid users versus nonopioid users (P = .06). Return of bowel function was delayed in opioid users compared with nonopioid users (P = .018). Incidence of superficial surgical site infection was increased among patients who used opioids preoperatively (27% vs 8.3%; P <.001) and remained so after multivariable logistic regression, (adjusted odds ratio 2.9, 95% confidence interval 1.2-6.7; P = .013).

CONCLUSION

Among patients undergoing ventral hernia repair, those with preoperative opioid use experienced an increased incidence of superficial surgical site infection compared with patients without preoperative opioid use. Further study is needed to understand the relationship between opioid use and surgical site infection after ventral hernia repair.

Associations Between Social Risk Factors and Surgical Site Infections After Colectomy and Abdominal Hysterectomy

IMPORTANCE

Surgical site infection (SSI) is an important patient safety outcome. Although social risk factors have been linked to many adverse health outcomes, it is unknown whether such factors are associated with higher rates of SSI.

OBJECTIVES

To determine whether social risk factors, including race/ethnicity, insurance status, and neighborhood income, are associated with higher rates of SSI after colectomy or abdominal hysterectomy, 2 surgical procedures for which SSI rates are publicly reported and included in pay-for-performance programs by Medicare and other groups.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed adults undergoing colectomy or abdominal hysterectomy, as captured in State Inpatient Databases for Arizona, Florida, Iowa, Massachusetts, Maryland, New York, and Vermont. Operations were performed in 2013 through 2014 at general acute care hospitals in the United States. Data analysis was conducted from October 2018 through June 2019.

EXPOSURES

Colectomy or hysterectomy.

MAIN OUTCOMES AND MEASURES

Postoperative complex SSI rates.

RESULTS

A total of 149 741 patients met the inclusion criteria, including 90 210 patients undergoing colectomies (mean [SD] age, 63.4 [15.6] years; 49 029 [54%] female; 74% white, 11% black, 9% Hispanic, and 5% other or unknown race/ethnicity) and 59 531 patients undergoing abdominal hysterectomies (mean [SD] age, 49.8 [11.8] years; 100% female; 52% white, 26% black, 14% Hispanic, and 8% other or unknown race/ethnicity). In the colectomy cohort, 34% had private insurance, 52% had Medicare, 9% had Medicaid, and 5% had other or unknown insurance or were uninsured; 24% were from the lowest quartile of median zip code income. In the hysterectomy cohort, 57% had private insurance, 16% had Medicare, 19% had Medicaid, and 3% had other or unknown insurance or were uninsured; 27% were from the lowest-income zip codes. Within 30 days of surgery, SSI rates were 2.55% for the colectomy cohort and 0.61% for the hysterectomy cohort. For colectomy, black race (adjusted odds ratio [AOR], 0.71; 95% CI, 0.61-0.82) was associated with lower odds of SSI, whereas Medicare (AOR, 1.25; 95% CI, 1.10-1.41), Medicaid (AOR, 1.23; 95% CI, 1.06-1.44), and low neighborhood income (AOR, 1.14; 95% CI, 1.01-1.29) were associated with higher odds of SSI. For hysterectomy, no social risk factors that were examined in this study had statistically significant associations with SSI after adjustment for clinical risk.

CONCLUSIONS AND RELEVANCE

Inconsistent associations between social risk factors and SSIs were found. For colectomy, infection prevention programs targeting low-income groups may be important for reducing disparities in this postoperative outcome, and policy makers could consider taking social risk factors into account when evaluating hospital performance.

Surgical site infection: the "Achilles Heel" of all types of abdominal wall hernia reconstruction

PURPOSE

Surgical site infection is the most common hospital-acquired infection in surgical patients. Recently, public health organizations have updated prevention guidelines. This review discusses surgical site infections as a complication of abdominal wall reconstruction.

METHODS

The authors reviewed guidelines on prevention of surgical site infections from the Center for Disease Control and Prevention, World Health Organization, and National Institute for Health and Care Excellence and put them into context with the relevant abdominal wall reconstruction literature. This was the subject of the Nyhus-Wantz lecture given at The International Hernia Congress on March 14, 2018 in Miami, FL and is summarized here.

RESULTS

Routine use of preoperative antibiotics in prosthetic groin hernia repair is not supported by the available literature. High-quality data on antibiotic prophylaxis in ventral (both primary and incisional) hernia repair is lacking, but it is widely utilized and may reduce SSIs. Recommended preventative strategies discussed in this manuscript include: treatment of remote site infections, perioperative normothermia and normoglycemia, avoidance of hypoxemia, antiseptic preparation of surgical team hands and patient skin, treatment of obesity, smoking cessation, correction of malnutrition, and physical conditioning.

CONCLUSION

Surgical site infections lead to significant morbidity and mortality, hernia recurrences, prolonged hospital stay, and increased hospital costs. This makes surgical site infections the "Achilles Heel" of abdominal wall reconstruction. Strict adherence to standardized guidelines and preoperative optimization of patients' risk profiles are crucial to decrease the incidence of surgical site infections.

Modified 2-port laparoscopic herniorrhaphy with Kirschner wire in children: A retrospective review

BACKGROUND

Pediatric inguinal hernia is one of the most common diseases in children, and laparoscopy is the main surgical method. This study aims to evaluate the efficacy of a new modified 2-port laparoscopic herniorrhaphy with Kirschner wire (TLHK) for inguinal hernia in children.

METHODS

A total of 5304 children with inguinal hernia hospitalized at the Jiangmen Center Hospital from June 2003 to May 2016 were enrolled in this retrospective study. Four thousand one hundred thirty-five children underwent TLHK that comprised the observation group, while 1169 received single incision laparoscopy (SIL) as the control group (CG). A propensity score matched cohort study was conducted between these groups. We included all patients who were diagnosed as inguinal hernia and matched comparators with a proportion of 1:1. The propensity score was calculated using logistic regression with forward stepwise selection in 4 variables. The patients' operative details, intra- and postoperative complications, and postoperative hospital stay were analyzed. The follow-up lasted from 1 month to 2 years.

RESULTS

Among 5304 potential patients, the propensity score identified 270 (135 TLHK cases and 135 comparators) patients. The age, sex, body mass index, and the hernia type and location did not differ between CG and TLHK. TLHK group had a shorter operative time (unilateral: 17.4 ± 3.35 minutes vs 20.7 ± 3.71 minutes; bilateral: 20.4 ± 5.17 minutes vs 25.2 ± 5.43 minutes), less complications (2.10% vs 2.65%), lower recurrence rate (0% vs 4.44%), and similar hospital stay (2.3 ± 1.1 vs 2.1 ± 1.3) as compared with CG. No iliac vessel injury, spermatic cord vessels injury, vas deferens injury, or iatrogenic cryptorchidism occurred in either of the groups.

CONCLUSION

TLHK is a safe and feasible treatment for inguinal hernia in children due to less invasion and less recurrence rate than SIL.

Risk factors for postoperative infection after gastrointestinal surgery among adult patients with inflammatory bowel disease: Findings from a large observational US cohort study

Background and Aim

Postoperative infection (POI) is a major source of morbidity and prolongation of hospitalization in inflammatory bowel disease (IBD) patients. This large observational study was conducted to further describe risk factors and to quantify the proportion of POIs that are preventable.

Methods

We conducted a retrospective cohort analysis of the Optum US health insurance claims database. The study population included adults with ulcerative colitis (UC) or Crohn's disease (CD) who underwent lower gastrointestinal (GI) surgery of small intestine, colon, rectum, or anus during September 2014 to September 2016. Multiple logistic regression was used to identify and quantify risk factors and determine the proportion of infections that are preventable.

Results

A total of 3360 adult IBD patients with lower GI surgery were included in the study. Their mean age was 51 years, 52.5% were women, and 59.5% had CD. The 30‐day POI incidence was 15.1% (95% confidence interval: 14.0–16.4%). We identified the following nonmodifiable or procedural risk factors: history of POI, open procedure, red blood cell transfusion within 6 months, preoperative hospital stay of at least 4 days, lower GI ostomy surgery, lower GI resection surgery, and a history of chronic obstructive pulmonary disease. Modifiable risk factors included corticosteroid use and anemia prior to surgery, but few infections were attributable to these modifiable factors.

Conclusions

This large, observational, real‐world evidence study from the US found that the majority of the observed risk factors were nonmodifiable or procedure‐related. Corticosteroid use and anemia before surgery were identified as modifiable risk factors.

Effect of an Intravenous Dexamethasone Added to Caudal Local Anesthetics to Improve Postoperative Pain: A Systematic Review and Meta-analysis With Trial Sequential Analysis

BACKGROUND

Caudal anesthesia has been used for postoperative pain control in pediatric surgical patients, but the duration of the analgesic effect is occasionally unsatisfactory. Intravenous steroids have been shown to be effective for postsurgical pain management after certain surgeries. The aim of this meta-analysis with trial sequential analysis (TSA) was to evaluate the analgesic effect of steroids in patients administered with caudal anesthesia.

METHODS

This study was a systematic review and meta-analysis. A search of published literature was conducted in the MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases and in trial registration sites. Randomized controlled trials that compared intravenous steroids with a placebo in pediatric patients who had received caudal anesthesia for surgery were included in the study. The primary outcomes from the present meta-analysis were the analgesic duration and the number of patients who required rescue analgesics. The analgesic duration and incidence of rescue use were summarized using mean difference or risk ratio with a 97.5% confidence interval (CI), respectively. If the 97.5% CI of the mean difference or risk ratio included a value of 0 or 1, respectively, we considered the difference not to be significant. We used the random effects model to combine the results. Heterogeneity was quantified with the I statistic. The quality of the trials was evaluated using the Cochrane methodology. Moreover, a TSA with a risk of type 1 error of 2.5% and power of 90% was performed. We established the minimum clinically meaningful difference of analgesic duration as 3 hours. The target sample size for meta-analysis was also calculated in the TSA. We also assessed adverse events.

RESULTS

Six trials with 424 patients were included; 211 patients received intravenous steroids. All trials compared dexamethasone of at least 0.5 mg/kg dose with a placebo. Dexamethasone prolonged the duration of caudal analgesia (mean difference, 244 minutes; 97.5% CI, 188-300). Heterogeneity was considerable with an I value of 94.8%. Quality of evidence was very low. The TSA suggested that only 17.0% of the target sample size had been reached, but the cumulative Z score crossed the trial sequential monitoring boundary to indicate a benefit. Rescue use was reported in 4 studies with 260 patients. Rescue use was not significantly reduced in the dexamethasone group (risk ratio, 0.53; 97.5% CI, 0.09-3.30; I, 98.7%). No increase in adverse events was reported.

CONCLUSIONS

Intravenous dexamethasone prolongs the analgesic duration of caudal anesthesia. Trials to investigate the effectiveness of a lower dose of the dexamethasone in prolonging analgesic effects would be of interest. Further trials with a low risk of bias are necessary.

Plastic wound protectors decreased surgical site infections following laparoscopic-assisted colectomy for colorectal cancer: A retrospective cohort study

Laparoscopic surgery is widespread and safe for the management of patients with colorectal cancer (CRC). Although the use of standard surgical techniques can prevent perioperative wound infections, surgical site infections (SSIs) remain an unresolved complication in laparoscopic-assisted colectomy. The present study investigated the ability of plastic wound protectors applied to the extraction incision during the externalized portion of the procedure to reduce the rate of infection in laparoscopic-assisted colectomy. We completed a retrospective review of the medical records of patients who underwent nonemergent laparoscopic-assisted between January 2015 and June 2016. Outcomes for patients with and without the use of a wound protector were compared. A total of 109 patients were included in this study. There was 1 patient in the wound protector group (n = 57) and 7 in the nonwound protector group (n = 52) who developed a wound infection at the colon extraction site (P = .02). Furthermore, the average postoperative hospital stay in the wound protector group was shorter compared to the nonwound protector group (7.47 ± 0.24 vs 8.73 ± 0.54 days, P = .03). In conclusion, this study indicates that the use of a plastic wound protector during laparoscope-assisted colectomy does reduce postoperative wound infection rates, and the wound protectors are beneficial for specimen extraction and digestive tract reconstruction.

de Garengeot hernia with appendicitis treated by two-way-approach surgery: a case report

de Garengeot hernia is a rare subtype of a femoral hernia with incarceration of the appendix. This type of hernia usually presents with therapeutic dilemmas, especially because of the risk of surgical site infection (SSI). Our patient was a 74-year-old woman with a bulging mass and tenderness in the right inguinal area. Computed tomography revealed an incarcerated appendix, with appendicitis in the femoral hernia. Laparoscopic appendectomy was initially performed, followed by hernioplasty via the anterior approach to prevent properitoneal contamination. Some authors have recently reported cases successfully treated by laparoscopy. However, this type of hernia has a higher risk for SSI, compared with the risk involved in usual hernioplasty. Therefore, selection of the appropriate surgical approach to prevent wound infection is important, especially in the presence of appendicitis. We would like to highlight the usefulness of hybrid surgery, laparoscopic appendectomy and hernioplasty via the anterior approach to prevent SSIs.

Risk Factors for Surgical Site Infection After Cholecystectomy

Background

There are limited data on risk factors for surgical site infection (SSI) after open or laparoscopic cholecystectomy.

Methods

A retrospective cohort of commercially insured persons aged 18–64 years was assembled using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition codes for cholecystectomy from December 31, 2004 to December 31, 2010. Complex procedures and patients (eg, cancer, end-stage renal disease) and procedures with pre-existing infection were excluded. Surgical site infections within 90 days after cholecystectomy were identified by ICD-9-CM diagnosis codes. A Cox proportional hazards model was used to identify independent risk factors for SSI.

Results

Surgical site infections were identified after 472 of 66566 (0.71%) cholecystectomies; incidence was higher after open (n = 51, 4.93%) versus laparoscopic procedures (n = 421, 0.64%; P < .001). Independent risk factors for SSI included male gender, preoperative chronic anemia, diabetes, drug abuse, malnutrition/weight loss, obesity, smoking-related diseases, previous Staphylococcus aureus infection, laparoscopic approach with acute cholecystitis/obstruction (hazards ratio [HR], 1.58; 95% confidence interval [CI], 1.27–1.96), open approach with (HR, 4.29; 95% CI, 2.45–7.52) or without acute cholecystitis/obstruction (HR, 4.04; 95% CI, 1.96–8.34), conversion to open approach with (HR, 4.71; 95% CI, 2.74–8.10) or without acute cholecystitis/obstruction (HR, 7.11; 95% CI, 3.87–13.08), bile duct exploration, postoperative chronic anemia, and postoperative pneumonia or urinary tract infection.

Conclusions

Acute cholecystitis or obstruction was associated with significantly increased risk of SSI with laparoscopic but not open cholecystectomy. The risk of SSI was similar for planned open and converted procedures. These findings suggest that stratification by operative factors is important when comparing SSI rates between facilities.