What Mesh Should be Used in Hernia Repair?

Ventral hernia repair is one of the most frequently performed general surgery operations in the world, yet the treatment of clean-contaminated and contaminated cases remains controversial. Biologic mesh has been thought to resist infection, decrease chronic wound complications, and reduce the need for reoperation. Their use continues to be predominant in contaminated and dirty cases. This article is a comprehensive review of what mesh to choose in both clean and contaminated single-staged, open ventral hernia repair with further considerations of tissue incorporation characteristics, cost, safety profiles, complications, recurrence, and long-term outcomes.

Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days

BACKGROUND

Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF).

METHODS

SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation.

RESULTS

241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05).

CONCLUSION

Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study

BACKGROUND

Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study.

METHODS

A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated.

RESULTS

Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm² vs botulinum toxin A 289.7 ± 162.4 cm²; P = .73) (mean volume: 1,498.3 + 2,043.4 cm³ vs 2,914.7 + 6,539.4 cm³; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13).

CONCLUSION

In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

Laparoscopic versus robotic inguinal hernia repair: a single-center case-matched study

INTRODUCTION

Robotic inguinal hernia repair (RIHR) is becoming increasingly common and is the minimally invasive alternative to laparoscopic inguinal hernia repair (LIHR). Thus far, there is little data directly comparing LIHR and RIHR. The purpose of this study will be to compare outcomes for LIHR and RIHR at a single center.

METHODS

A prospective institutional hernia database was queried for patients who underwent transabdominal LIHR or RIHR from 2012 to 2020. The patients were then matched based on the surgeon performing the operation (single, expert hernia surgeon) and laterality of repair. Standard descriptive statistics were used.

RESULTS

There were 282 patients who met criteria for the study, 141 LIHR and 141 RIHR; 32.6% of patients in each group had a bilateral repair (p = 1.00). LIHR patients were slightly younger (54.4 ± 15.6 vs 58.6 ± 13.8; p = 0.03) but similar in terms of BMI (27.1 ± 5.1 vs 29.1 ± 2.1; p = 0.70) and number of comorbidities (2.9 ± 2.5 vs 2.6 ± 2.2; p = 0.59). Operative time was found to be longer in the RIHR group, but when evaluating RIHR at the beginning of the study versus the end of the study, there was a 50-min decrease in operative time (p < 0.01). Recurrence rates were low for both groups (0.7% vs 1.4%; p = 0.38) with mean follow-up time 13.0 ± 13.3 months. There was only one wound infection, which was in the robotic group. No patients required return to the operating room for complications relating to their surgery. There were no 30-day readmissions in the LIHR group and three 30-day readmissions in the RIHR group (p = 0.28).

CONCLUSION

LIHR and RIHR are both performed with low morbidity and have comparable overall outcomes. The total charges were increased in the RIHR group. Either LIHR or RIHR may be considered when performing inguinal hernia repair and should depend on surgeon and patient preference; continued evaluation of the outcomes is warranted.

Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury

BACKGROUND

The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury.

METHODS

A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h.

RESULTS

There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021).

CONCLUSION

Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.

Robotic hernia surgery IV. English version : Robotic parastomal hernia repair. Video report and preliminary results

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

Intercostal Lung Hernia Following Deep Inferior Epigastric Perforator Reconstruction

Acquired lung hernias typically result from trauma or intra-thoracic surgery is defined as the protrusion of lung parenchyma beyond the anatomic boundaries of the thoracic wall. A 40-year-old woman underwent deep inferior epigastric perforator (DIEP) breast reconstruction following her mastectomies. Post-operatively, she returned to the emergency department with severe chest pain, shortness of breath, and localized chest swelling. CT angiography demonstrated intercostal right lung hernia with concern for incarceration. She returned emergently to the operating room. The lung was reduced, but the flap was ultimately determined to be nonviable and was removed. Post-operative course was uneventful and the patient recovered well. Intercostal lung hernia is an uncommon clinical entity that has not previously been described as a complication of DIEP breast reconstruction. Its development is associated with significant morbidity including flap loss in this case. Early recognition of this rare complication is essential to avoid more severe sequelae of tissue ischemia.

[Robotic hernia surgery IV. German version : Robotic parastomal hernia repair. Video report and preliminary results]

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

Best Study Strategy for the NBME Clinical Science Surgery Exam

INTRODUCTION

Providing medical students with effective study strategies is paramount in fostering their success on the NBME Clinical Science Surgery exam. As of yet, there has not been a comprehensive inquiry into a study strategy for this exam. We aim to identify if the following are associated with higher NBME raw exam scores: (1) the use of popular study materials, (2) the number of study materials used, and (3) the amount of time spent studying throughout the clerkship.

METHODS

Over the period of 1 academic year, third-year medical students at our institution were administered a survey during their surgical clerkship inquiring about study materials used and hours spent studying per week. The data were then matched to students' raw NBME scores and then depersonalized. A total of 82 of 193 (42%) students responded with an overall average raw score of 76.74 on the NBME Clinical Science Surgery exam. By comparing our data to the NBME national average of 70 with a standard deviation of 8, a z test was used to compare the population mean to our sample means.

RESULTS

When investigating resources used, the combination of using an online question bank and a high yield review book yielded a high z score (6.23) and using 4 resources yielded the highest z score (6.28). Regarding study hours, the highest z scores were seen when students studied for 6 to 10 hours per week during the first half of the clerkship, and 11 to 15 hours per week during the second half of the clerkship (5.76 and 6.02, respectively).

CONCLUSIONS

In conclusion, higher NBME Clinical Science Surgery exam scores were correlated with the use of multiple and varied types of resources and increasing study time closer to the exam date. The resources and methods utilized by students achieving the highest exam scores can be recommended by surgical educators and employed by other medical students to foster academic success.