Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement vs. primary suture only in midline laparotomies (PRIMA): long-term outcomes of a multicentre, double-blind, randomised controlled trial

Background

Incisional hernia occurs approximately in 40% of high-risk patients after midline laparotomy. Prophylactic mesh placement has shown promising results, but long-term outcomes are needed. The present study aimed to assess the long-term incisional hernia rates of the previously conducted PRIMA trial with radiological follow-up.

Methods

In the PRIMA trial, patients with increased risk of incisional hernia formation (AAA or BMI ≥27 kg/m2) were randomised in a 1:2:2 ratio to primary suture, onlay mesh or sublay mesh closure in three different countries in eleven institutions. Incisional hernia during follow-up was diagnosed by any of: CT, ultrasound and physical examination, or during surgery. Assessors and patients were blinded until 2-year follow-up. Time-to-event analysis according to intention-to-treat principle was performed with the Kaplan-Meier method and Cox proportional hazard models. Trial registration: NCT00761475 (ClinicalTrials.gov).

Findings

Between 2009 and 2012, 480 patients were randomized: 107 primary suture, 188 onlay mesh and 185 sublay mesh. Five-year incisional hernia rates were 53.4% (95% CI: 40.4-64.8), 24.7% (95% CI: 12.7-38.8), 29.8% (95% CI: 17.9-42.6), respectively. Compared to primary suture, onlay mesh (HR: 0.390, 95% CI: 0.248-0.614, p < 0.001) and sublay mesh (HR: 0.485, 95% CI: 0.309-0.761, p = 0.002) were associated with a significantly lower risk of incisional hernia development.

Interpretation

Prophylactic mesh placement remained effective in reducing incisional hernia occurrence after midline laparotomy in high-risk patients during long-term follow-up. Hernia rates in the primary suture group were higher than previously anticipated.

Funding

B. Braun.

Twelve-year outcomes of watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: a randomised controlled trial

Background

Inguinal hernia belongs to the most common surgical pathology worldwide. Approximately, one third is asymptomatic. The value of watchful waiting (WW) in patients with asymptomatic or mildly symptomatic inguinal hernia has been established in a few randomised controlled trials (RCTs). The aim of this study was to assess long-term outcomes of a RCT comparing WW and elective surgery.

Methods

In the original study, men aged ≥50 years with an asymptomatic or mildly symptomatic inguinal hernia were randomly assigned to WW or elective repair. In the present study, the primary outcome was the 12-year crossover rate to surgery, secondary outcomes were time-to-crossover, patient regret, pain, quality of life and incarceration. Dutch Trial Registry: NTR629.

Findings

Out of 496 originally analysed patients, 488 (98.4%) were evaluable for chart review (WW: n = 258, surgery: n = 230), and 200 (41.0%) for telephone contact (WW: n = 106, surgery: n = 94) between November 2021 and March 2022 with a median 12 years follow-up (IQR 9-14). After 12 years, the estimated cumulative crossover rate to surgery was 64.2%, which was higher in mildly symptomatic than in asymptomatic patients (71.7% versus 60.4%, HR 1.451, 95% CI: 1.064-1.979). Time-to-crossover was longer in asymptomatic patients (50% after 6.0 years versus 2.0 years, p = 0.019). Patient regret was higher in the WW group (37.7 versus 18.0%, p = 0.002), as well as pain/discomfort (p = 0.031). Quality of life did not differ (p = 0.737). In the WW group, incarceration occurred in 10/255 patients (3.9%).

Interpretation

During 12-year follow-up, most WW patients crossed over to surgery, significantly earlier with mildly symptomatic hernia. Considering the relatively low incarceration rate, WW might still be an option in asymptomatic patients with a clear preference and being well-informed about pros and cons.

Funding

The initial trial was funded by the Netherlands Organisation for Health Research and Development (ZonMW). This long-term study did not receive funding.

Computer-Assisted Surgical Anatomical Mapping of the Antebrachial Cutaneous Nerves: An Anatomical Study with a Proposition for Alternative, Cutaneous Nerve-Sparing Anterior Elbow Incisions

It is common practice to assess the distance from nerves to anatomical structures in centimeters, but patients have various body compositions and anatomical variations are common. The purpose of this study was therefore to assess the relative distance from cutaneous nerves around the elbow to surrounding anatomical landmarks by providing a stacked image that displays the average position of cutaneous nerves around the elbow. The aim was to research possibilities for adjusting common skin incisions in the anterior elbow so that cutaneous nerve injury may be avoided.

Methods

The lateral antebrachial cutaneous nerve (LABCN) and medial antebrachial cutaneous nerve (MABCN) were identified in the coronal plane around the elbow joint in 10 fresh-frozen human arm specimens. Marked photographs of the specimens were analyzed using computer-assisted surgical anatomical mapping (CASAM). Common anterior surgical approaches to the elbow joint and the distal humerus were then compared with merged images, and nerve-sparing alternatives are proposed.

Results

The arm was divided longitudinally, from medial to lateral in the coronal plane, into 4 quarters. The LABCN crossed the central-lateral quarter of the interepicondylar line (i.e., was somewhat lateral to the midline at the level of the elbow crease) in 9 of 10 specimens. The MABCN ran medial to the basilic vein and crossed the most medial quarter of the interepicondylar line. Thus, 2 of the quarters were either free of cutaneous nerves (the most lateral quarter) or contained a distal cutaneous branch in only 1 of 10 specimens (the central-medial quarter).

Conclusions

The Boyd-Anderson approach, which is often used to access anteromedial structures of the elbow, should be placed slightly further medially than traditionally advised. The distal part of the Henry approach should deviate laterally, so that it runs over the mobile wad. In distal biceps tendon surgery, the risk of cutaneous nerve injury may be reduced if a single distal incision is placed slightly more laterally (in the most lateral quarter), as in the modified Henry approach. If proximal extension is required, LABCN injury may be prevented by using the modified Boyd-Anderson incision, which runs in the central-medial quarter.

Clinical Relevance

Cutaneous nerve injury may be prevented by slightly altering the commonly used skin incisions around the elbow on the basis of the safe zones that were identified by depicting the cumulative course of the MABCN and LABCN using CASAM.

The incidence of extraction site incisional hernia after minimally invasive colorectal surgery: a systematic review and meta-analysis

AIM

Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction.

METHOD

A systematic review and meta-analysis was conducted using the PRISMA guidelines. Single-armed and multiple-armed cohort studies and randomized controlled trials regarding minimally invasive colorectal surgery were searched from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias within the studies was assessed using the Cochrane ROBINS-I and RoB 2 tool.

RESULTS

Thirty six studies were included, with a total 11,788 patients. The pooled extraction site IH rate was 16.0% for midline (n = 4081), 9.3% for umbilical (n = 2425), 5.2% for transverse (n = 3213), 9.4% for paramedian (n = 134) and 2.1% for Pfannenstiel (n = 1449). Nonmidline extraction (transverse and paramedian) showed significantly lower odds ratios (ORs) for IH when compared with midline extraction (including umbilical). Pfannenstiel extraction resulted in a significantly lower OR for IH compared with midline [OR 0.12 (0.50-0.30)], transverse [OR 0.25 (0.13-0.50)] and umbilical (OR 0.072 [0.033-0.16]) extraction sites. The risks of surgical site infection, seroma/haematoma or wound dehiscence were not significantly different in any of the analyses.

CONCLUSION

Pfannenstiel extraction is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid specimen extraction in the midline.

A preoperative prediction model for anastomotic leakage after rectal cancer resection based on 13.175 patients

INTRODUCTION

This study aims to develop a robust preoperative prediction model for anastomotic leakage (AL) after surgical resection for rectal cancer, based on established risk factors and with the power of a large prospective nation-wide population-based study cohort.

MATERIALS AND METHODS

A development cohort was formed by using the DCRA (Dutch ColoRectal Audit), a mandatory population-based repository of all patients who undergo colorectal cancer resection in the Netherlands. Patients aged 18 years or older were included who underwent surgical resection for rectal cancer with primary anastomosis (with or without deviating ileostomy) between 2011 and 2019. Anastomotic leakage was defined as clinically relevant leakage requiring reintervention. Multivariable logistic regression was used to build a prediction model and cross-validation was used to validate the model.

RESULTS

A total of 13.175 patients were included for analysis. AL was diagnosed in 1319 patients (10%). A deviating stoma was constructed in 6853 patients (52%). The following variables were identified as significant risk factors and included in the prediction model: gender, age, BMI, ASA classification, neo-adjuvant (chemo)radiotherapy, cT stage, distance of the tumor from anal verge, and deviating ileostomy. The model had a concordance-index of 0.664, which remained 0.658 after cross-validation. In addition, a nomogram was developed.

CONCLUSION

The present study generated a discriminative prediction model based on preoperatively available variables. The proposed score can be used for patient counselling and risk-stratification before undergoing rectal resection for cancer.

OC-014 FAVOURABLE OUTCOMES AFTER RETRO-RECTUS (RIVES-STOPPA) MESH REPAIR AS TREATMENT FOR NON-COMPLEX VENTRAL ABDOMINAL WALL HERNIA, A SYSTEMATIC REVIEW AND META-ANALYSIS

Aim

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For noncomplex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard. Level-1 evidence confirming this presumed superiority is lacking. The aim of this study was to assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality.

Material & Methods

Five databases were searched for studies reporting retro-rectus repair. Randomized and non-randomized studies were included. Outcomes were pooled with random-effects models.

Results

Ninety-three studies representing 12,440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% [95% confidence interval (CI): 2.2%–4.2%, n = 11,049] after minimally 12 months and 4.1%, (95%CI: 2.9%–5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2%–6.4%, n = 4891) and 5.5% (95%CI: 4.4%–6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (odds ratios (OR): 0.27, 95%CI: 0.15–0.51, P &lt; 0.001) and equal recurrence rates compared to intraperitoneal onlay mesh (IPOM) repair (OR: 0.92, 95%CI: 0.75–1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03–3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%) and SSI (1.5%), albeit based on non-randomized studies.

Conclusions

Retro-rectus repair results in excellent outcomes, superior or similar to other techniques for all outcomes except SSI. The latter occurred less after IPOM repair, which is usually laparoscopic.

Applicability of devices available for the measurement of intracompartmental pressures: a cadaver study

Purpose

The indication for surgical treatment of the chronic exertional compartment syndrome is evaluated by measuring intracompartmental pressures. The validity of these invasive intracompartmental pressure measurements are increasingly questioned in the absence of a standardized test protocol and uniform cut-off values. The aim of the current study was to test compartment pressure monitors and needles for uniformity, thereby supporting the physician’s choice in the selection of appropriate test materials.

Methods

A compartment syndrome was simulated in embalmed above-knee cadaveric leg specimen. Four different terminal devices (Compass manometer, Stryker device, Meritrans transduce, and arterial line) were tested with 22 different needle types. Legs were pressurized after introduction of the four terminal devices in the anterior compartment, using the same needle type. Pressure was recorded at a 30-second interval for 11 minutes in total. Before and after pressurization, the intravenous bag of saline was weighed.

Results

The simulation of a compartment syndrome resulted in intracompartmental pressure values exceeding 100 mmHg in 17 of the 22 legs (77%). In the other five legs, a smaller built-up of pressure was seen, although maximum intracompartmental pressure was in between 70 and 100 mmHg. The intraclass correlation coefficient was above 0.700 for all possible needle types. Excellent to good resemblance was seen in 16 out of 22 instrumental setups (73%). The mean volume of saline infusion required in runs that exceeded 100 mmHg (309 ± 116 ml) was significantly lower compared to the legs in which 100 mmHg was not achieved (451 ± 148 ml; p = 0.04).

Conclusion

The intracompartmental pressure recordings of the four terminal devices were comparable, when tested with a standardized pressurization model in a human cadaver model. None of the included terminal devices or needle types were found to be superior. The results provide evidence for more diverse material selection when logistic choices for intracompartmental pressure measurement devices are warranted.

Level of evidence

Level IV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00529-0.

P048 A NEW MODALITY FOR BIOMECHANICAL VALIDATION OF CLOSURE TECHNIQUES OF LAPAROTOMIES

Aim

Incisional hernia remains one of the most frequent complications after abdominal surgery. Several closure techniques exist. However, fundamental biomechanical understanding of these techniques and of the differences in clinical outcomes are still lacking. It is thought that distribution of lateral forces on the midline plays a role. Testing in a clinical setting is limited by sample sizes, costs and ethical regulations. We propose a preclinical ex vivo model in which multiple closure configurations can be tested in a controlled setting, eliminating interfering variables existing in previously published, more complex abdominal wall models. Consequently, this allows a valid comparison between closure modalities based on biomechanical merits.

Material and Methods

The experimental set-up is represented by a vertical tensile load tester, in which a sutured tissue sample is clamped. The tissue samples are covered with a fine, random speckle pattern via miniscule ink droplets. A high-resolution camera captures the speckles as the tissue is subjected to linear pulling forces. Image analysis documenting relative movement of speckles as a means for measuring tissue deformation is performed in ex-vivo tissue samples, resulting in specific objective biomechanical characteristics for each closure configuration.

Results

Local tissue strain fields are visualized, and compared between closure modalities and correlated to known linear forces applied to the tissue. The latest results will be shared and discussed.

Conclusions

A new modality for biomechanical evaluation of closure techniques has been developed. Further validation and serial experiments with different closure modalities with and without mesh reinforcement can be performed in order to determine the biomechanically optimal suture-technique for fascial closure.

P045 MEDIALIZATION AFTER COMBINED ANTERIOR AND POSTERIOR COMPONENT SEPARATION IN GIANT INCISIONAL HERNIA SURGERY, AN ANATOMICAL STUDY

Aim

To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation (ACS, PCS) is often performed. In extreme patients, ACS and PCS may be combined. The aim of this study was to assess the additional medialization after simultaneous ACS and PCS.

Material and Methods

Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), ACS and PCS, the order in which the component separation techniques (CST) were performed was reversed for the contralateral side. Medialization was measured at three reference points.

Results

ACS provided most medialization for the anterior rectus sheath, PCS provided most medialization for the posterior rectus sheath. After combined CST total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional PCS after ACS provided 15% to 16%, and additional ACS after PCS provided 32% to 38% of the total medialization after combined CST. For the posterior rectus sheath, additional PCS after ACS provided 50% to 59%, and additional ACS after PCS provided 11% to 17% of the total medialization after combined CST. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization.

Conclusions

ACS provided most medialization of the anterior rectus sheath and PCS provided most medialization of the posterior rectus sheath. Combined CST provides marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks.

O26 INFECTIOUS COMPLICATION IN RELATION TO THE PROPHYLACTIC MESH POSITION: THE PRIMA TRIAL REVISITED

Aim

Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position.

Material and Methods

Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure.

Results

Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group.

Conclusions

Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

P130 HYBRID OPERATION TECHNIQUE FOR INCISIONAL HERNIA REPAIR, A SYSTEMATIC REVIEW AND META-ANALYSIS OF INTRA- AND POSTOPERATIVE COMPLICATIONS

Aim

Incisional hernia (IH) occurs approximately in 15% of patients after midline surgery. Surgical treatment for IHs include a solely open or solely laparoscopic approach with mesh placement. Recently, hybrid (combined laparoscopic and open) approaches are being performed. This systematic review evaluates the perioperative complications of hybrid incisional hernia repair (HIHR).

Material and Methods

EMBASE, Medline via OvidSP, Web of Science, Cochrane and Google Scholar databases were searched. Studies providing data on intra- and postoperative complications in patients who underwent HIHR were included. Data on intra- and postoperative complications were extracted and meta-analyses were performed. Study quality was assessed with the Newcastle Ottowa Scale, ROBINS-I tool, and Cochrane risk of bias. PROSPERO registration: CRD42020175053.

Results

Results: Nine studies (n = 1596 patients) were included. Five studies compared intra-operative complications between HIHR and laparoscopic incisional hernia repair (LIHR) with a pooled incidence of 1.8% in HIHR group and 2.8% in LIHR group (p = 0.13). Comparison of postoperative prevalence of surgical site occurrences (SSOs) (24% versus 31%, p = 0.02) and surgical site occurrences requiring interventions (SSOPIs) (1.5% versus 4.1%, p &lt; 0.01) were in favour of the HIHR group. Overall postoperative complications seemed to occur less frequent in the HIHR group, though no hard statements could be made due to the vast heterogeneity in reporting between studies.

Conclusions

Although the majority of studies were retrospective and included a small number of patients, HIHR led to less SSOs and SSOPIs compared to LIHR. This systematic review forms a strong invitation for more randomized controlled trials to confirm the benefits of this approach.

O18 LONG-TERM CROSSOVER RATE FROM WATCHFUL WAITING TO SURGERY OF INITIALLY MIDLY SYMPTOMATIC OR ASYMPTOMATIC INGUINAL HERNIAS IN MEN AGES 50 YEARS AND OLDER

Aim

Inguinal hernia (IH) belongs to the most common surgical pathology worldwide. Approximately, one third of patients are asymptomatic. Watchful waiting (WW) has been regarded as a justifiable treatment option, but doubts still exist since high crossover (CO) rates to surgery may occur. The aim of this study is to assess the CO rates after 13-year follow-up of our randomized controlled trial (RCT).

Material and Methods

In our original study, 496 men with an asymptomatic or mildly symptomatic IH were randomly assigned to elective repair or WW. A retrospective review was conducted of patients initially assigned to WW. Primary outcome was CO rate to surgery. Secondary outcomes included reason for crossing over and time between initial randomisation and the CO to surgery.

Results

In the original RCT, 95 of 262 WW patients electively crossed over to surgery (35.4%) after 32.9 months. Currently, 212 of the 262 (81.0%) WW patients were reviewed, and 133/212 (62.7%) crossed over to surgery. Median follow-up was 13 years (range, 8-15 years). Mean time to CO was 35.2 months SD (40.8). Motivations for crossing over to surgery were predominantly due to progression of symptoms (83.5%), and in 8 (3.8%) cases due to an emergency event.

Conclusions

In the presented population, WW on the long-term remains a safe strategy, saving one third of patients an operation, although CO to surgery will likely occur. Insights into the natural course of untreated inguinal hernia that are valuable during patient counseling can be offered in the form of long-term CO rate due to progression of symptoms.

O45 OUTCOMES OF INCISIONAL HERNIA REPAIR SURGERY AFTER MULTIPLE RE-RECURRENCES: A PROPENSITY SCORE MATCHED ANALYSIS

Aim

Patients with a re-recurrent hernia may account for up to 20% of all incisional hernia (IH) patients. IH repair in this population may be complex due to an altered anatomical and biological situation as a result of previous procedures and outcomes of IH repair in this population have not been thoroughly assessed. This study aims to assess outcomes of IH repair by dedicated hernia surgeons in patients who have already had two or more re-recurrences.

Material and Methods

A propensity score matched analysis was performed using a registry-based, prospective cohort. Patients who underwent IH repair after ≥ 2 re-recurrences operated between 2011 and 2018 and who fulfilled 1 year follow-up visit were included. Patients with similar follow-up who underwent primary IH repair were propensity score matched (1:3) and served as control group. Patient baseline characteristics, surgical and functional outcomes were analyzed and compared between both groups.

Results

Seventy-three patients operated on after ≥ 2 IH re-recurrences were matched to 219 patients undergoing primary IH repair. After propensity score matching, no significant differences in patient baseline characteristics were present between groups. The incidence of re-recurrence was similar between groups (≥ 2 re-recurrences: 25% versus control 24%, p = 0.811). The incidence of complications, as well as long-term pain, was similar between both groups.

Conclusions

IH repair in patients who have experienced multiple re-recurrences results in outcomes comparable to patients operated for a primary IH with a similar risk profile. Further surgery in patients who have already experienced multiple hernia re-recurrences is justifiable when performed by a dedicated hernia surgeon.

Hybrid operation technique for incisional hernia repair: a systematic review and meta-analysis of intra- and postoperative complications

Background

Incisional hernia (IH) occurs approximately in 15% of patients after midline surgery. Surgical treatment for IHs include a solely open or solely laparoscopic approach with mesh placement. Recently, hybrid (combined laparoscopic and open) approaches have been introduced. This systematic review evaluates perioperative complications of hybrid incisional hernia repair (HIHR).

Methods

EMBASE, Medline via OvidSP, Web of Science, Cochrane and Google Scholar databases were searched. Studies providing data on intra- and postoperative complications in patients who underwent HIHR were included. Data on intra- and postoperative complications were extracted and meta-analyses were performed. Study quality was assessed with the Newcastle Ottowa Scale, ROBINS-I tool, and Cochrane risk of bias. PROSPERO registration: CRD42020175053.

Results

Eleven studies (n = 1681 patients) were included. Five studies compared intra-operative complications between HIHR and laparoscopic incisional hernia repair (LIHR) with a pooled incidence of 1.8% in HIHR group and 2.8% in LIHR group (p = 0.13). Comparison of postoperative prevalence of surgical site occurrences (SSOs) (23% versus 26%, p = 0.02) and surgical site occurrences requiring interventions (SSOPIs) (1.5% versus 4.1%, p < 0.01) were in favour of the HIHR group. Overall postoperative complications seemed to occur less frequent in the HIHR group, though no hard statements could be made due to the vast heterogeneity in reporting between studies.

Conclusion

Although the majority of studies were retrospective and included a small number of patients, HIHR seemingly led to less SSOs and SSOPIs. This systematic review forms a strong invitation for more randomized controlled trials to confirm the benefits of this approach.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02497-3.

Calcification of the Aorta-Iliac Trajectory as a Risk Factor for Anastomotic Leakage in Colorectal Surgery: Individual Patient Data Meta-Analysis and Systematic Review

OBJECTIVE

The purpose of this review is to evaluate the relevance of vascular calcification as a potential risk factor for anastomotic leakage in colorectal surgery.

METHOD

The Embase, Medline, PubMed, and Cochrane databases and Google Scholar were systematically searched. Studies that assessed calcification of the aorta-iliac trajectory in patients who underwent colorectal surgery were included. An independent patient data meta-analysis was performed as follows: based on the heterogeneity of the study population, a "random-effects model" or "fixed-effects model" was used to perform a multivariable logistic regression and calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I2-test.

RESULTS

From a total of 457 articles retrieved, eight fell within the scope of the review, with a total of 2010 patients. Anastomotic leakage was found at a mean rate of 11.1% (SD 4.9%). In these eight studies, four different calcification scoring methods were used, which made a single structured meta-analysis not feasible. Therefore, an independent patient data meta-analysis on the most frequently used calcification scoring method was performed, including three studies with a total of 396 patients. After multivariable analyses, no significant association was found between anastomotic leakage and the amount of calcification in the aorta-iliac trajectory. The remaining three scoring methods were evaluated. In four of the five studies, vascular calcification was associated with anastomotic leakage after colorectal surgery.

CONCLUSION

In contrast to previous studies, an individual patient data meta-analysis found no association between calcification and anastomotic leakage in colorectal surgery after multivariable analysis that considered a single calcification measurement method. In addition, this study demonstrated several scoring methods for arterial calcification and the need for a standardized technique. Therefore, the authors would recommend prospective studies using a calcification scoring method that includes grade of stenosis due to its potential to preoperatively improve perfusion by endovascular treatment.

Medialization after combined anterior and posterior component separation in giant incisional hernia surgery, an anatomical study

BACKGROUND

To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation is often performed. In patients with an extreme diameter hernia, anterior component separation and posterior component separation may be combined. The aim of this study was to assess the additional medialization after simultaneous anterior component separation and posterior component separation.

METHODS

Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Medialization was measured at 3 reference points.

RESULTS

Anterior component separation provided most medialization for the anterior rectus sheath, posterior component separation provided most medialization for the posterior rectus sheath. After combined component separation techniques total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional posterior component separation after anterior component separation provided 15% to 16%, and additional anterior component separation after posterior component separation provided 32% to 38% of the total medialization after combined component separation techniques. For the posterior rectus sheath, additional posterior component separation after anterior component separation provided 50% to 59%, and additional anterior component separation after posterior component separation provided 11% to 17% of the total medialization after combined component separation techniques. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization.

CONCLUSION

Anterior component separation provided most medialization of the anterior rectus sheath and posterior component separation provided most medialization of the posterior rectus sheath. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks.

Consensus paper on postural dysfunction: recommendations for prevention, diagnosis and therapy

Good fundamentals of posture and balance are essential for the efficient performance of both simple daily tasks and more complex movement patterns. In particular, postural balance is the ability to keep the body in equilibrium and to regain balance after the shift of body segments: postural control mechanisms of integration of the visual, vestibular and foot afferential channels contribute to this. This document provides recommendations based on scientific evidence, clinical practice, and consensus between experts concerning the prevention, diagnosis, and treatment of postural dysfunction at the three stages of life as the developmental age, adult age, and old age > 65 years and follows the "National Guidelines on Classification and Measuring of Posture and its Dysfunctions" per the Italian Ministry of Health (December 2017). The paper answers four main questions: i) "Which measures can be adopted to prevent postural dysfunctions?" ii) "What can we do in order to make a correct diagnosis of postural dysfunction?" iii) "What are the correct treatment programs for postural dysfunctions?" iv) Which professional competencies and experiences are useful for preventing, diagnosing and treating postural dysfunctions? By the Consensus of the Experts and the scientific evidence, emerge that the approach to postural dysfunctions requires a multidisciplinary and interdisciplinary team. Furthermore, rehabilitation treatment interventions must be specific to the age groups that have been indicated, to consider the integration of the main systems and subsystems of postural control that change with age.

Perfectionistic Concerns are Detrimental to Skill Learning for Minimally Invasive Surgery

BACKGROUND

The pursuit of high standards and continuous self-improvement are important aspects of a professional attitude in medicine. However, when identity and self-esteem are dependent on flawless performance, healthy striving can become perfectionism. The present study examines the influence of perfectionism on the learning process of basic instrument handling for minimally invasive surgery (MIS).

METHODS

Thirty medical students volunteered to participate in the study (19 females, 11 males). The mean age was 19.8 years (SD = 1.8). The Perfectionism Inventory was used to determine the degree of perfectionist characteristics in two main factors: Self-evaluative perfectionism and Conscientious perfectionism. Participants practiced with the loops and wire task on a surgical simulator and were tested for skill retention within 48 hours. During practice instrument movement was captured in three-dimensional space using a Leap Motion controller. Performance was assessed by time and total path length travelled by the instruments.

RESULTS

Self-evaluative perfectionism was negatively related to skill retention with regard to movement efficiency, but did not predict change in average time on task. The Conscientious perfectionism factor was not a predictor of skill retention with regard to path length or completion time.

RESULTS

Self-evaluative perfectionism was a significant predictor of change in average pathlength between sessions but did not predict change in average time. The Conscientious perfectionism factor was not a predictor of changes in path length or completion time.

CONCLUSIONS

Overly negative self-evaluation during MIS skill practice undermined the learning process. Trainees with self-critical perfectionistic tendencies may not optimally benefit from their efforts during practice.

Infectious Complication in Relation to the Prophylactic Mesh Position: The PRIMA Trial Revisited

BACKGROUND

Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position.

STUDY DESIGN

Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure.

RESULTS

Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group.

CONCLUSIONS

Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

Outcomes of Incisional Hernia Repair Surgery After Multiple Re-recurrences: A Propensity Score Matched Analysis

Background

Patients with a re-recurrent hernia may account for up to 20% of all incisional hernia (IH) patients. IH repair in this population may be complex due to an altered anatomical and biological situation as a result of previous procedures and outcomes of IH repair in this population have not been thoroughly assessed. This study aims to assess outcomes of IH repair by dedicated hernia surgeons in patients who have already had two or more re-recurrences.

Methods

A propensity score matched analysis was performed using a registry-based, prospective cohort. Patients who underwent IH repair after ≥ 2 re-recurrences operated between 2011 and 2018 and who fulfilled 1 year follow-up visit were included. Patients with similar follow-up who underwent primary IH repair were propensity score matched (1:3) and served as control group. Patient baseline characteristics, surgical and functional outcomes were analyzed and compared between both groups.

Results

Seventy-three patients operated on after ≥ 2 IH re-recurrences were matched to 219 patients undergoing primary IH repair. After propensity score matching, no significant differences in patient baseline characteristics were present between groups. The incidence of re-recurrence was similar between groups (≥ 2 re-recurrences: 25% versus control 24%, p = 0.811). The incidence of complications, as well as long-term pain, was similar between both groups.

Conclusion

IH repair in patients who have experienced multiple re-recurrences results in outcomes comparable to patients operated for a primary IH with a similar risk profile. Further surgery in patients who have already experienced multiple hernia re-recurrences is justifiable when performed by a dedicated hernia surgeon.

Supplementary Information

The online version of this article (10.1007/s00268-021-05952-5) contains supplementary material, which is available to authorized users.

The effect of preferred music on mental workload and laparoscopic surgical performance in a simulated setting (OPTIMISE): a randomized controlled crossover study

BACKGROUND

Worldwide, music is commonly played in the operation room. The effect of music on surgical performance reportedly has varying results, while its effect on mental workload and key surgical stressor domains has only sparingly been investigated. Therefore, the aim is to assess the effect of recorded preferred music versus operating room noise on laparoscopic task performance and mental workload in a simulated setting.

METHODS

A four-sequence, four-period, two-treatment, randomized controlled crossover study design was used. Medical students, novices to laparoscopy, were eligible for inclusion. Participants were randomly allocated to one of four sequences, which decided the exposure order to music and operation room noise during the four periods. Laparoscopic task performance was assessed through motion analysis with a laparoscopic box simulator. Each period consisted of ten alternating peg transfer tasks. To account for the learning curve, a preparation phase was employed. Mental workload was assessed using the Surgery Task Load Index. This study was registered with the Netherlands Trial Register (NL7961).

RESULTS

From October 29, 2019 until March 12, 2020, 107 participants completed the study, with 97 included for analyzation. Laparoscopic task performance increased significantly during the preparation phase. No significant beneficial effect of music versus operating room noise was observed on time to task completion, path length, speed, or motion smoothness. Music significantly decreased mental workload, reflected by a lower score of the total weighted Surgery Task Load Index in all but one of the six workload dimensions.

CONCLUSION

Music significantly reduced mental workload overall and of several previously identified key surgical stressor domains, and its use in the operating room is reportedly viewed favorably. Music did not significantly improve laparoscopic task performance of novice laparoscopists in a simulated setting. Although varying results have been reported previously, it seems that surgical experience and task demand are more determinative.

Assessment of Flexion Elongation Relation and Type of Failure after Capsulodesis

Background  Injury of the scapholunate interosseous ligament is the most frequently diagnosed cause of carpal instability and can be treated with a Mayo capsulodesis procedure. During this procedure, a radially based flap of the dorsal radiocarpal complex is attached to the lunate. The procedure attempts to reduce flexion of the scaphoid and restore the scapholunate relationship by crossing the scapholunate interval. To obtain a better understanding of the biomechanical properties and possibly improve the postoperative rehabilitation process, a better understanding of the reconstructions biomechanics is needed. Methods  Ten dorsal intercarpal ligament capsulodesis were performed on embalmed wrists to assess the flexion elongation relation at the dorsal intercarpal reconstruction, the dorsal intercarpal complex, and the type of failure during flexion of the wrist. Results  The mean elongation of the dorsal intercarpal reconstruction at 70-degree flexion was 0.8 mm. During flexion, the dorsal intercarpal reconstruction showed no ligament tears or failure of the bone anchor. The mean elongation of the dorsal intercarpal complex was 3.9 mm at 70 degrees. During subsequent repeated flexion, four sutures to connect the dorsal intercarpal complex to the surrounding tissue loosened between 55 and 60 degrees. Conclusions  These findings suggest that capsulodesis can safely withstand flexion of the wrist until 50 degrees. Clinical Relevance  Clinicians should consider the opportunity to start early with controlled active motion. Level of Evidence  Not applicable.

Arterial calcification is a risk factor for anastomotic leakage after esophagectomy: A systematic review and meta-analysis

BACKGROUND

Leakage of the esophago-gastrostomy after esophagectomy with gastric tube reconstruction is a serious complication. Anastomotic leakage occurs in up to 20% of patients and a compromised perfusion of the gastric tube is thought to play an important role. This meta-analysis aimed to investigate whether arterial calcification is a risk factor for anastomotic leakage in esophageal surgery.

METHOD

Embase, Medline, PubMed, Cochrane databases and Google scholar databases were systematically searched for studies that assessed arterial calcification of the thoracic aorta, celiac axis including its branches, or the superior mesenteric artery in patients that underwent esophagectomy with gastric tube reconstruction. The degree of calcification was classified as absent, minor or major. A "random-effects model" was used to calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I²-test.

RESULTS

From the 456 articles retrieved, seven studies were selected including 1.860 patients. The median (range) of anastomotic leakage was 17.2% (12.7-24.8). Meta-analysis showed a statistically significant association between increased calcium score and anastomotic leakage for the thoracic aorta (OR 2.18(CI 1.42-3.34)), celiac axis (OR 1.62(CI 1.15-2.29)) and right post-celiac axis (common hepatic, gastroduodenal and right gastroepiploic arteries) (OR 2.69(CI 1.27-5.72)). Heterogeneity was observed for analysis on calcification of the thoracic aorta and celiac axis (I² = 71% and 59%, respectively) but not for the right branches of the celiac axis (I² = 0%).

CONCLUSION

This meta-analysis, including good quality studies, showed a statistically significant association between arterial calcification and anastomotic leakage in patients who underwent esophagectomy with gastric tube reconstruction.

Functional outcomes in symptomatic versus asymptomatic patients undergoing incisional hernia repair: Replacing one problem with another? A prospective cohort study in 1312 patients

BACKGROUND

Incisional hernias can be associated with pain or discomfort. Surgical repair especially mesh reinforcement, may likewise induce pain. The primary objective was to assess the incidence of pain after hernia repair in patients with and without pre-operative pain or discomfort. The secondary objectives were to determine the preferred mesh type, mesh location and surgical technique in minimizing postoperative pain or discomfort.

MATERIALS AND METHODS

A registry-based prospective cohort study was performed, including patients undergoing incisional hernia repair between September 2011 and May 2019. Patients with a minimum follow-up of 3-6 months were included. The incidence of hernia related pain and discomfort was recorded perioperatively.

RESULTS

A total of 1312 patients were included. Pre-operatively, 1091 (83%) patients reported pain or discomfort. After hernia repair, 961 (73%) patients did not report pain or discomfort (mean follow-up = 11.1 months). Of the pre-operative asymptomatic patients (n = 221), 44 (20%, moderate or severe pain: n = 14, 32%) reported pain or discomfort after mean follow-up of 10.5 months. Of those patients initially reporting pain or discomfort (n = 1091), 307 (28%, moderate or severe pain: n = 80, 26%) still reported pain or discomfort after a mean follow-up of 11.3 months postoperatively.

CONCLUSION

In symptomatic incisional hernia patients, hernia related complaints may be resolved in the majority of cases undergoing surgical repair. In asymptomatic incisional hernia patients, pain or discomfort may be induced in a considerable number of patients due to surgical repair and one should be aware if this postoperative complication.

Traumatic Meniscal Tears Are Associated With Meniscal Degeneration

BACKGROUND

Meniscal tears are traditionally classified into traumatic versus degenerative tears. Although this classification plays a major role in clinical decision making, no consensus exists on the exact definition of a traumatic or degenerative tear, and the histopathological basis for this classification is unclear.

PURPOSE

To assess the histological degree of meniscal degeneration in patients with a traumatic meniscal tear, as compared with intact meniscal tissue and osteoarthritic meniscal tissue.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Traumatically torn meniscal tissue was collected during arthroscopic partial meniscectomy. As a control group, intact meniscal tissue was used from transfemoral amputations or direct postmortem dissections. Meniscal tissue from osteoarthritic knees was obtained during total knee replacement surgery. Meniscal tissue was processed, stained, and histologically analyzed with the Pauli scoring system (range, 0-18), comprising the subdomains surface integrity, cellularity, collagen organization, and matrix staining. Scoring was performed by 2 independent observers, blinded to condition, region, and patient data of the meniscus.

RESULTS

The traumatic meniscal tear group contained 43 patients (34 men; median age, 29 years; median body mass index [BMI], 24 kg/m²); the intact meniscal tissue group, 8 patients (3 men; median age, 58 years; median BMI, 30 kg/m²); and the osteoarthritic group, 14 patients (4 men; median age, 66 years; median BMI, 28 kg/m²). After adjustment for sex, age, and BMI, patients with a traumatic meniscal tear had a significantly higher histological score than patients with intact meniscal tissue (2.7-point difference; P = .035). Histological score between the traumatic and osteoarthritic groups was not different.

CONCLUSION

Traumatically torn menisci possess a higher degree of degeneration than intact menisci. Our results suggest that patients with a traumatic meniscal tear may already have had a certain degree of meniscal degeneration. These findings potentially challenge the classic view of traumatic versus degenerative meniscal tears.

CLINICAL RELEVANCE

Our findings provide a better understanding of the tissue condition of a torn meniscus. This knowledge may help clinicians decide on choice of treatment and may lead to new perspectives to prevent knee osteoarthritis in patients with a torn meniscus.

Differences in biomechanics of abdominal wall closure with and without mesh reinforcement: A study in post mortem human specimens

INTRODUCTION

Small bites for the closure of the abdominal wall after midline laparotomy result in significantly less incisional hernias in comparison with large bites. However, fundamental knowledge of underlying biomechanical phenomena remains sparse. The objective of this study was to develop a digital image correlation-based method to compare different suturing techniques in terms of strain pattern after closure of a midline laparotomy in a passive model just after the time of surgery.

METHODS

A digital image correlation (DIC)-based method was used for the comparison of strain fields on the external surface of the myofascial abdominal wall (skin and subcutaneous fat removed) among six configurations, including an intact linea alba in five post mortem human specimens. The second configuration comprised primary mass closure with small bites (five mm between two consecutive stitches and five mm distance from the incision, 5x5 mm). The third configuration was primary mass closure with large bites (ten mm by ten mm, 10x10 mm). The fourth, fifth and sixth configuration comprised primary mass closure with large bites and the placement of a mesh in onlay position with two different overlaps and the use of glue to simulate the integration of the mesh within the soft tissue.

RESULTS

No visible difference was observed between 5x5 and 10x10 mm closure configurations. However, the use of mesh as suture line reinforcement highlighted a stiffer behavior of the midline area for similar intra-abdominal pressure, which was amplified when a larger mesh overlap was used. However, the whole abdominal wall showed quite similar shapes for the various configurations, except for the configuration with mesh reinforcement and the use of glue.

CONCLUSION

Mesh reinforcement incited lower opening tension profiles in the midline area of the abdominal wall. following closure of the linea alba in median laparotomy. The next step should be to investigate the impact of mesh location (e.g. retromuscular) and different time points after surgery.

Safe approach for fixation of first metacarpal fractures: an anatomical study

This anatomical study defines a safe zone for percutaneous or minimally invasive fixation of first metacarpal fractures in order to avoid injury of the superficial branch of the radial nerve and the dorsal branch of the radial artery. The courses of the nerve and artery branches were marked in 20 embalmed cadaver specimens. With computer-assisted surgical anatomy mapping, a large diversity in the anatomical patterns for the nerve and a consistent pattern for the artery were found. Based on these findings, we conclude that transfixation of the first and the second metacarpals with K-wires placed in the distal 75% of both the first and second metacarpals is the safest way to avoid damages to the nerve and artery branches during fracture fixation.

Comparison of different modalities for the diagnosis of parastomal hernia: a systematic review

PURPOSE

Parastomal hernia (PSH) is a common complication following stoma formation. The incidence of PSH varies widely due to several factors including differences in diagnostic modality, observer, definition, and classification used for diagnosing PSH. The aim of this systematic review was to evaluate the diagnostic accuracy of the modalities used to identify PSH.

METHODS

Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar databases were searched. Studies reporting PSH incidence rates detected by two or more different diagnostic modalities or inter-observer variation on one diagnostic modality were included. Article selection and assessment of study quality were conducted independently by two researchers using Cochrane Collaboration's tool for assessing risk of bias. PROSPERO registration: CRD42018112732.

RESULTS

Twenty-nine studies (n = 2514 patients) were included. Nineteen studies compared CT to clinical examination with relative difference in incidence rates ranging from 0.64 to 3.0 (n = 1369). Overall, 79% of studies found an increase in incidence rate when using CT. Disagreement between CT and clinical examination ranged between 0 and 37.3% with pooled inter-modality agreement Kappa value of 0.64 (95% CI 0.52-0.77). Four studies investigated the diagnostic accuracy of ultrasonography (n = 103). Compared with peroperative diagnosis, CT and ultrasonography both seemed accurate imaging modalities with a sensitivity of 83%.

CONCLUSION

CT is an accurate diagnostic modality for PSH diagnosis and increases PSH detection rates, as compared with clinical examination. Studies that specially focus on the diagnostic accuracy are needed and should aim to take patient-reported outcomes into account. A detailed description of the diagnostic approach, modality, definition, and involved observers is prerequisite for future PSH research.

Sigmoid resection with primary anastomosis versus the Hartmann's procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis

PURPOSE

The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann's procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence.

METHODS

A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs).

RESULTS

From a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients.

CONCLUSION

Although between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann's procedure in selected patients with Hinchey III or IV diverticulitis.

Use of the Humeral Head as a Reference Point to Prevent Axillary Nerve Damage during Proximal Fixation of Humeral Fractures: An Anatomical and Radiographic Study

Introduction

Treatment of proximal humeral fractures with plate osteosynthesis or intramedullary nail fixation in humeral shaft fractures with a proximal locking bolt carries the risk of iatrogenic injury of the axillary nerve. The purpose of this anatomical study is to define a more reliable safe zone to prevent iatrogenic axillary nerve injury using the humeral head instead of the acromion as a (radiographic) reference point during operative treatment.

Materials and methods

Anatomical dissection and labeling of the axillary nerve and branches was performed on 10 specially embalmed human specimens. Standard AP and straight lateral radiographs were made. The distances were measured indirectly from the cranial tip of the humerus to the axillary nerve on radiographs.

Results

The median distance from the cranial tip of the humerus to the axillary nerve was 52 mm. The mean number of axillary nerve branches was 3. The distances from the cranial tip of the humerus to the nerve (branch) varied from 23 to 78 mm. The median distance from the proximal (anterior) branch was 36 mm, to the second branch 47 mm, 54 mm to the third branch and 73 mm to the fourth branch. The axillary nerve moves along with the humerus in cranial and caudal direction when the subacromial space varies.

Conclusion

This study shows that the position of the axillary nerve can be better determent using the cranial tip of the humerus as a reference point instead of the acromion. Furthermore, it is unsafe to place the proximal locking bolts in the zone between 24 mm and 78 mm from the cranial tip of the humerus. The greatest chance to cause a lesion of the main branch of the axillary nerve is in the zone between 48 mm and 58 mm caudal from the tip of the humeral head.

How to cite this article

Theeuwes HP, Potters JW, Bessems JHJM, et al. Use of the Humeral Head as a Reference Point to Prevent Axillary Nerve Damage during Proximal Fixation of Humeral Fractures: An Anatomical and Radiographic Study. Strategies Trauma Limb Reconstr 2020;15(2):63–68.

Incisional Hernia Cannot Be Diagnosed by a Patient-Reported Diagnostic Questionnaire

BACKGROUND

Incisional hernia (IH) is one of the most frequent complications after abdominal surgery. Follow-up with regard to IH remains challenging. Physical examination and imaging to diagnose IH are time-consuming and costly, require devotion of both the physician and patient, and are often not prioritized. Therefore, a patient-reported diagnostic questionnaire for the diagnosis of IH was developed. Objective of this study was to validate this questionnaire in a consecutive sample of patients.

METHODS

All patients above 18 y of age who underwent abdominal surgery with a midline incision at least 12 mo ago were eligible for inclusion. Included patients visited the outpatient clinic where they filled out the diagnostic questionnaire and underwent physical examination. The questionnaire answers were compared with the physical examination results. The diagnostic accuracy of the entire questionnaire was assessed by multivariable logistic regression.

RESULTS

In total, 241 patients visited the outpatient clinic prospectively. 54 (22%) patients were diagnosed with IH during physical examination. The area under the receiver operating characteristic curve of the diagnostic questionnaire was 0.82. Sensitivity and specificity were respectively 81.5% and 77.5%. The positive and negative predictive values were 51.2% and 94%, respectively. Ten (19%) patients with IH were missed by the questionnaire.

CONCLUSIONS

The patient-reported diagnostic questionnaire as currently proposed cannot be used to diagnose IH. However, given the high negative predictive value, the questionnaire might be used to rule out an IH. Long-term follow-up for the diagnosis of IH should be performed by clinical examination.

Outcomes After Elective Colorectal Surgery by 2 Surgeons Versus 1 Surgeon in a Low-Volume Hospital

Background. Improved patient outcomes after colorectal surgery in high-volume hospitals are leading to centralization of colorectal surgery. However, it is desirable to strive for optimal quality of colorectal surgery in low-volume hospitals. This study aimed to assess the effect of the number of surgeons involved in the surgical procedure on patient outcomes in a low-volume hospital. Methods. All patients who underwent elective colorectal surgery with construction of a primary anastomosis between January 1, 2007, and December 31, 2015, were included in this retrospective cohort. The propensity score was used to adjust for confounding. Results. A total of 429 patients were included. One hundred forty-three patients (33.3%) were operated by 1 surgeon and 286 patients (66.7%) were operated by 2 surgeons. Patients operated by 2 surgeons were younger, more often male, and had a higher body mass index. A multivariate analysis with propensity scores revealed that surgery with 2 surgeons was associated with fewer reoperations (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.9, P = .038). Colorectal anastomotic leakage (OR = 0.6, 95% CI = 0.2-1.3, P = .204) and mortality (OR = 0.8, 95% CI = 0.2-3.7, P = .807) were not associated with the number of surgeons involved in the surgical procedure. Conclusion. The present study shows that elective colorectal surgery in a low-volume hospital performed by 2 surgeons resulted in fewer reoperations. This might positively influence patient outcomes and might be related to increased surgical quality as compared with procedures performed by only 1 surgeon.

Risk Factors for Incarceration in Patients with Primary Abdominal Wall and Incisional Hernias: A Prospective Study in 4472 Patients

BACKGROUND

Incarceration of primary and incisional hernias often results in emergency surgery. The objective of this study was to evaluate the relation of defect size and location with incarceration. Secondary objectives comprised identification of additional patient factors associated with an incarcerated hernia.

METHODS

A registry-based prospective study was performed of all consecutive patients undergoing hernia surgery between September 2011 and February 2016. Multivariate logistic regression was performed to identify risk factors for incarceration.

RESULTS

In total, 83 (3.5%) of 2352 primary hernias and 79 (3.7%) of 2120 incisional hernias had a non-reducible incarceration. For primary hernias, a defect width of 3-4 cm compared to defects of 0-1 cm was significantly associated with an incarcerated hernia (OR 2.85, 95% CI 1.57-5.18, p = 0.0006). For incisional hernias, a defect width of 3-4 cm compared to defects of 0-2 cm was significantly associated with an incarceration (OR 2.14, 95% CI 1.07-4.31, p = 0.0324). For primary hernias, defects in the peri- and infra-umbilical region portrayed a significantly increased odds for incarceration as compared to supra-umbilical defects (OR 1.98, 95% CI 1.02-3.85, p = 0.043). Additionally, in primary hernias age, BMI, and constipation were associated with incarceration. In incisional hernias age, BMI, female sex, diabetes mellitus and ASA classification were associated with incarceration.

CONCLUSION

For primary and incisional hernias, mainly defects of 3-4 cm were associated with incarceration. For primary hernias, mainly defects located in the peri- and infra-umbilical region were associated with incarceration. Based on patient and hernia characteristics, patients with increased odds for incarceration may be selected and these patients may benefit from elective surgical treatment.

Pitfalls and clinical recommendations for the primary lumbar hernia based on a systematic review of the literature

Purpose

The lumbar abdominal wall hernia is a rare hernia in which abdominal contents protrude through a defect in the dorsal abdominal wall, which can be of iatrogenic, congenital, or traumatic origin. Two anatomical locations are known: the superior and the inferior lumbar triangle. The aim of this systematic review is to provide a clear overview of the existing literature and make practical clinical recommendations for proper diagnosis and treatment of the primary lumbar hernia.

Methods

The systematic review was conducted according to the PRISMA guidelines. A systematic search in PubMed, MEDLINE, and EMBASE was performed, and all studies reporting on primary lumbar hernias were included. No exclusion based on study design was performed. Data regarding incarceration, recurrence, complications, and surgical management were extracted.

Results

Out of 670 eligible articles, 14 were included and additional single case reports were analysed separately. The average quality of the included articles was 4.7 on the MINORS index (0–16). Risk factors are related to increased intra-abdominal pressure. CT scanning should be performed during pre-operative workup. Available evidence favours laparoscopic mesh reinforcement, saving open repair for larger defects. Incarceration was observed in 30.8% of the cases and 2.0% had a recurrence after surgical repair. Hematomas and seromas are common complications, but surgical site infections are relatively rare.

Conclusion

The high risks of incarceration in lumbar hernias demand a relatively fast elective repair. The use of a mesh is recommended, but the surgical approach should be tailored to individual patient characteristics and risk factors.

Non-operative treatment as a strategy for patients with parastomal hernia: a multicentre, retrospective cohort study

AIM

Parastomal hernia is the most common complication following stoma construction. Surgical treatment is usually chosen over non-operative treatment, but a clear rationale for the choice of management is often lacking. This study aims to investigate the reasons for non-operative treatment, cross-over rates and postoperative complications.

METHOD

A multicentre, retrospective cohort study was conducted. Patients diagnosed with a parastomal hernia between January 2007 and December 2012 were included. Data on baseline characteristics, primary surgery and hernias were collected. For non-operative treatment, reasons for this treatment and cross-over rates were evaluated. For all patients undergoing surgery (surgical treatment and cross-overs), complication and recurrence rates were analysed.

RESULTS

Of the 80 patients included, 42 (53%) were in the surgical treatment group and 38 (48%) in the non-operative treatment group. Median follow-up was 46 months (interquartile range 24-72). The reasons for non-operative treatment were absence of symptoms in 12 patients (32%), comorbidities in nine (24%) and patient preference in three (7.9%). In 14 patients (37%) reasons were not documented. Eight patients (21%) crossed over from non-operative treatment to surgical treatment, of whom one needed emergency surgery. In 23 patients (55%), parastomal hernia recurred after the original surgical treatment, of whom 21 (91%) underwent additional repair.

CONCLUSION

Parastomal hernia repair is associated with high recurrence and additional repair rates. Non-operative treatment has a relatively low cross-over and emergency surgery rate. Given these data, non-operative treatment might be a better choice for patients without complaints or with comorbidities.

Possibility of quantitative T2-mapping MRI of cartilage near metal in high tibial osteotomy: A human cadaver study

T2-mapping is a widely used quantitative MRI technique in osteoarthritis research. An important challenge for its application in the context of high tibial osteotomy (HTO) is the presence of metallic fixation devices. In this study, we evaluated the possibility of performing T2-mapping after a HTO, by assessing the extent of magnetic susceptibility artifacts and the influence on T2 relaxation times caused by two commonly used fixation devices. T2-mapping with a 3D fast spin-echo sequence at three Tesla was performed on 11 human cadaveric knee joints before and after implantation of a titanium plate and screws (n = 5) or cobalt chrome staples (n = 6). Mean T2 relaxation times were calculated in six cartilage regions, located in the distal and posterior cartilage of femoral condyles and the cartilage of tibial plateaus, both medially and laterally. T2 relaxation times before and after the implantation were compared with paired t-tests and Wilcoxon rank tests. Due to the extent of the magnetic susceptibility artifact, it was not possible to segment the knee cartilage and thus calculate T2 relaxation times in the lateral weight-bearing femoral and tibial cartilage regions only in the cobalt chrome group. In all cartilage regions of the titanium implanted knees and those unaffected by artifacts due to cobalt chrome implants, T2 relaxation times did not significantly differ between the two scans. Our results suggest that accurate T2-mapping after a HTO procedure is possible in all areas after implantation of a titanium fixation device and in most areas after implantation of a cobalt chrome fixation device. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1206-1212, 2018.

Comparing different modalities for the diagnosis of incisional hernia: a systematic review

PURPOSE

Incisional hernia (IH) is the most frequent complication after abdominal surgery. The diagnostic modality, observer, definition, and diagnostic protocol used for the diagnosis of IH potentially influence the reported prevalence. The objective of this systematic review is to evaluate the diagnostic accuracy of different modalities used to identify IH.

METHODS

Embase, MEDLINE OvidSP, Web of Science, Google Scholar, and Cochrane databases were searched to identify studies diagnosing IH. Studies comparing the IH detection rate of two different diagnostic modalities or inter-observer variability of one modality were included. Quality assessment of studies was done by Cochrane Collaboration's tool. Article selection and data collection were performed independently by two researchers. PROSPERO registration: CRD42017062307.

RESULTS

Fifteen studies representing a total of 2986 patients were included. Inter-observer variation for CT-scan ranged from 11.2 to 69% (n = 678). Disagreement between ultrasound and CT-scan ranged between 6.6 and 17% (n = 221). Ten studies compared physical examination to CT-scan or ultrasound. Disagreement between physical examination and imaging ranged between 7.6 and 39% (n = 1602). Between 15 and 58% of IHs were solely detected by imaging (n = 483). Relative increase in IH prevalence for imaging compared to physical examination ranged from 0.92 to 2.4 (n = 1922).

CONCLUSIONS

Ultrasound or CT-scan will result in substantial additional IH diagnosis. Lack of consensus regarding the definition of IH might contribute to the disagreement rates. Both the observer and diagnostic modality used could be additional factors explaining variability in IH prevalence and should be reported in IH research.

Optimal surgical approach for the treatment of Quervains disease: A surgical-anatomical study

AIM

To determine which of the common used incision techniques has the lowest chance of iatrogenic damage to the nerves which at risk are the superficial branch of the radial nerve (SBRN) and the Lateral Antebrachial Cutaneous Nerve (LABCN).

METHODS

Twenty embalmed arms were dissected and the course of the SBRN and the LABCN in each individual arm was marked and the distance between the two branches of the SBRN at the location of the First Extensor Compartment (FEC) was measured. This data was used as input in a visualization tool called Computer Assisted Anatomy Mapping (CASAM) to map the course of the nerves in each individual arm.

RESULTS

This image visualizes that in 90% of the arms, one branch of the SBRN crosses the FEC and one branch runs volar to the compartment. The distance between the two branches was 7.8 mm at the beginning of the FEC and 10.2 mm at the end. Finally the angle of incision at which the chance of damage to the nerves is lowest, is 19.4 degrees volar to the radius.

CONCLUSION

CASAM shows the complexity of the course of the SBRN over the FEC. None of the four widely used incision techniques has a significantly lower chance of iatrogenic nerve damage. Surgical skills are paramount to prevent iatrogenic nerve damage.

A step towards stereotactic navigation during pelvic surgery: 3D nerve topography

Background

Long-term morbidity after multimodal treatment for rectal cancer is suggested to be mainly made up by nerve-injury-related dysfunctions. Stereotactic navigation for rectal surgery was shown to be feasible and will be facilitated by highlighting structures at risk of iatrogenic damage. The aim of this study was to investigate the ability to make a 3D map of the pelvic nerves with magnetic resonance imaging (MRI).

Methods

A systematic review was performed to identify a main positional reference for each pelvic nerve and plexus. The nerves were manually delineated in 20 volunteers who were scanned with a 3-T MRI. The nerve identifiability rate and the likelihood of nerve identification correctness were determined.

Results

The analysis included 61 studies on pelvic nerve anatomy. A main positional reference was defined for each nerve. On MRI, the sacral nerves, the lumbosacral plexus, and the obturator nerve could be identified bilaterally in all volunteers. The sympathetic trunk could be identified in 19 of 20 volunteers bilaterally (95%). The superior hypogastric plexus, the hypogastric nerve, and the inferior hypogastric plexus could be identified bilaterally in 14 (70%), 16 (80%), and 14 (70%) of the 20 volunteers, respectively. The pudendal nerve could be identified in 17 (85%) volunteers on the right side and in 13 (65%) volunteers on the left side. The levator ani nerve could be identified in only a few volunteers. Except for the levator ani nerve, the radiologist and the anatomist agreed that the delineated nerve depicted the correct nerve in 100% of the cases.

Conclusion

Pelvic nerves at risk of injury are usually visible on high-resolution MRI with dedicated scanning protocols. A specific knowledge of their course and its application in stereotactic navigation is suggested to improve quality of life by decreasing the likelihood of nerve injury.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6086-3) contains supplementary material, which is available to authorized users.

2D and 3D assessment of sustentaculum tali screw fixation with or without Screw Targeting Clamp

INTRODUCTION

Precise placement of sustentaculum tali screw(s) is essential for restoring anatomy and biomechanical stability of the calcaneus. This can be challenging due to the small target area and presence of neurovascular structures on the medial side. The aim was to evaluate the precision of positioning of the subchondral posterior facet screw and processus anterior calcanei screw with or without a Screw Targeting Clamp. The secondary aim was to evaluate the added value of peroperative 3D imaging over 2D radiographs alone.

METHODS

Twenty Anubifix™ embalmed, human anatomic lower limb specimens were used. A subchondral posterior facet screw and a processus anterior calcanei screw were placed using an extended lateral approach. A senior orthopedic trauma surgeon experienced in calcaneal fracture surgery and a senior resident with limited experience in calcaneal surgery performed screw fixation in five specimens with and in five specimens without the clamp. 2D lateral and axial radiographs and a 3D recording were obtained postoperatively. Anatomical dissection was performed postoperatively as a diagnostic golden standard in order to obtain the factual screw positions. Blinded assessment of quality of fixation was performed by two surgeons.

RESULTS

In 2D, eight screws were considered malpositioned when placed with the targeting device versus nine placed freehand. In 3D recordings, two additional screws were malpositioned in each group as compared to the golden standard. As opposed to the senior surgeon, the senior resident seemed to get the best results using the Screw Targeting Clamp (number of malpositioned screws using freehand was eight, and using the targeting clamp five). In nine out of 20 specimens 3D images provided additional information concerning target area and intra-articular placement. Based on the 3D assessment, five additional screws would have required repositioning. Except for one, all screw positions were rated equally after dissection when compared with 3D examinations.

CONCLUSION

This study does not show a substantial benefit between the Screw Targeting Clamp and the freehand technique as well between experienced and inexperienced surgeons. Data suggest that the clamp might help positioning sustentaculum tali screws, especially for inexperienced surgeons. Perioperative 3D recordings facilitate identification of malpositioned screws.

Oxygen therapies and their effects on wound healing

Oxygen is an important factor for wound healing. Although several different therapies investigated the use of oxygen to aid wound healing, the results of these studies are not unequivocal. This systematic review summarizes the clinical and experimental studies regarding different oxygen therapies for promoting wound healing, and evaluates the outcomes according the methodological details. A systematic literature search was conducted using Embase, Medline, Web of Science, Cochrane, PubMed publisher, and Google Scholar libraries. Clinical and experimental studies investigating oxygen for wound healing were selected. Included articles were categorized according to the kind of therapy, study design, and wound type. The methodological details were extracted and analyzed. Sixty-five articles were identified and divided in three different oxygen therapies: Local oxygen therapy, hyperbaric oxygen therapy, and supplemental inspired oxygen therapy. More than half of the included local oxygen and hyperbaric oxygen studies had one or more significant positive outcomes, 77 and 63%, respectively. Supplemental inspired oxygen therapy during gastrointestinal and vascular surgery was more likely to have a positive result than during other surgical interventions reducing surgical site infections. These many positive outcomes promote the use of oxygen treatment in the stimulation of wound healing. However, the lack of clinical studies and vast methodological diversity made it impossible to perform a proper comparison within and between the different therapies. Further randomized clinical studies are warranted to examine the value of these therapies, especially studies that investigate the more patient-friendly oxygen dressings and topical wound oxygen therapies. Also, to achieve more solid and consistent data, studies should use more standardized methods and subjects.

Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial

BACKGROUND

Incisional hernia is a frequent long-term complication after abdominal surgery, with a prevalence greater than 30% in high-risk groups. The aim of the PRIMA trial was to evaluate the effectiveness of mesh reinforcement in high-risk patients, to prevent incisional hernia.

METHODS

We did a multicentre, double-blind, randomised controlled trial at 11 hospitals in Austria, Germany, and the Netherlands. We included patients aged 18 years or older who were undergoing elective midline laparotomy and had either an abdominal aortic aneurysm or a body-mass index (BMI) of 27 kg/m² or higher. We randomly assigned participants using a computer-generated randomisation sequence to one of three treatment groups: primary suture; onlay mesh reinforcement; or sublay mesh reinforcement. The primary endpoint was incidence of incisional hernia during 2 years of follow-up, analysed by intention to treat. Adjusted odds ratios (ORs) were estimated by logistic regression. This trial is registered at ClinicalTrials.gov, number NCT00761475.

FINDINGS

Between March, 2009, and December, 2012, 498 patients were enrolled to the study, of whom 18 were excluded before randomisation. Therefore, we included 480 patients in the primary analysis: 107 were assigned primary suture only, 188 were allocated onlay mesh reinforcement, and 185 were assigned sublay mesh reinforcement. 92 patients were identified with an incisional hernia, 33 (30%) who were allocated primary suture only, 25 (13%) who were assigned onlay mesh reinforcement, and 34 (18%) who were assigned sublay mesh reinforcement (onlay mesh reinforcement vs primary suture, OR 0·37, 95% CI 0·20-0·69; p=0·0016; sublay mesh reinforcement vs primary suture, 0·55, 0·30-1·00; p=0·05). Seromas were more frequent in patients allocated onlay mesh reinforcement (34 of 188) than in those assigned primary suture (five of 107; p=0·002) or sublay mesh reinforcement (13 of 185; p=0·002). The incidence of wound infection did not differ between treatment groups (14 of 107 primary suture; 25 of 188 onlay mesh reinforcement; and 19 of 185 sublay mesh reinforcement).

INTERPRETATION

A significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement compared with sublay mesh reinforcement and primary suture only. Onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy.

FUNDING

Baxter; B Braun Surgical SA.