Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study.

OBJECTIVE: Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN: A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING: Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS: All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. RESULTS: The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS: Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Multiphase preclinical assessment of a novel device to locate unintentionally retained surgical sharps: a proof-of-concept study.

BACKGROUND: Retained surgical sharps (RSS) is a "never event" that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device ("Melzi Sharps Finder®" or MSF) in effective detection of RSS. METHODS: The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF. RESULTS: In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control (98.1% vs. 22.0%, p < 0.001; 1.64 min ± 1.12vs. 3.34 min ± 1.28, p < 0.001). It also had increased accuracy of determining the presence of a needle and decreased time to reach this decision (100% vs. 58.8%, p < 0.001; 1.69 min ± 1.43 vs. 4.89 min ± 0.63, p < 0.001). In-the second study, the accuracy of determining the presence of a needle and time to reach this decision were comparable in each group (88.9% vs. 100% vs. 84.5%, p < 0.49; 2.2 min ± 2.2 vs. 2.7 min ± 2.1vs. 2.8 min ± 1.7, p = 0.68). In the third study, MSF group had higher accuracy in determining the presence of a needle and decreased time to reach this decision than the control (97.0% vs. 46.7%, p < 0.001; 2.0 min ± 1.5 vs. 3.9 min ± 1.4; p < 0.001). Multivariable analysis showed that MSF use was independently associated with an accurate determination of the presence of a needle (OR 12.1, p < 0.001). CONCLUSIONS: The use of MSF in this study's RSS models facilitated the determination of presence and localization of RSS as shown by the increased rate of identification of a needle, decreased time to identification and higher accuracy in determining the presence of a needle. This device may be used in conjunction with radiography as it gives live visual and auditory feedback for users during the search for RSS.

Asystole Following Concomitant Intravenous Administration of Neostigmine and Dexmedetomidine in a Patient With Acute Colonic Pseudo-Obstruction.

Acute colonic pseudo-obstruction (ACPO) is a condition characterized by acute dilation of the large bowel without evidence of mechanical obstruction that occurs in a variety of hospitalized patients with many predisposing factors. Management includes supportive care and limitation of offending medications with mainstays of treatment of neostigmine administration and colonic decompression. We report the case of a critically ill patient with ACPO who experienced bradycardia and a brief episode of asystole when receiving concomitant dexmedetomidine and neostigmine infusions but who later remained hemodynamically stable when receiving propofol and neostigmine infusions. The bradycardia and associated hemodynamic instability experienced while on dexmedetomidine and neostigmine infusions were rapidly corrected with atropine and cessation of offending agents. Because ACPO is encountered frequently and the use of dexmedetomidine as a sedative agent in the ICU is increasing, practitioners should be aware of the additive risk of bradycardia and potential for asystole with the combination of neostigmine and dexmedetomidine. Electronic drug interaction databases should be updated and drug information sources should include a drug-drug interaction between dexmedetomidine and neostigmine to reduce the likelihood of concomitant administration.

The influence of a statewide "Stay-at-Home" order on trauma volume and patterns at a level 1 trauma center in the united states.

The COVID pandemic of 2020 resulted in unprecedented restrictions of public life in most countries around the world, and many hospital systems experienced dramatic decreases in non-COVID related patient admissions. We aimed to compare trauma volumes, patient characteristics, and trauma mechanisms at a large, urban Level 1 trauma center in the United States during a state-wide "State of Emergency" and "stay-at-home" order to corresponding historic dates. All adult trauma activations from March 1 through April 30, 2020 and a historic control from March 1 through April 30, 2018 and 2019 were reviewed in the institution's trauma registry. Trauma volumes, patient characteristics, and trauma mechanisms were compared over time as increasingly stricter COVID-related restrictions were enacted in the Commonwealth of Virginia. After declaration of a state-wide "Public Health Emergency" on March 17, 2020, the daily number of trauma activations significantly declined to a mean of 4.7 (standard deviation, SD = 2.6), a decrease by 43% from a mean of 8.2 (SD = 0.3) for the same dates in 2018 and 2019. Trauma activations during COVID restrictions vs. historic control were characterized by significantly higher prevalence of chronic alcohol use (15.5% vs. 6.8%, p < 0.01), higher median (25th - 75th percentile) Injury Severity Score of 9 (5 - 16) vs. 6 (4 - 14), p = 0.01, and shorter median (25th - 75th percentile) length of hospital stay of 2 (1 - 6) days vs. 3 (1 - 7) days, p = 0.03. The COVID-related Public Health Emergency and "stay-at-home" order in the Commonwealth of Virginia dramatically reduced overall trauma volumes with minor but interesting changes in trauma patterns.

Detecting direct oral anticoagulants in trauma patients using liquid chromatography-mass spectrometry: A novel approach to medication reconciliation.

BACKGROUND: Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS)-based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival. METHODS: Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay. RESULTS: Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity. CONCLUSION: This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients. LEVEL OF EVIDENCE: Diagnostic Test, level III.

Medications and patient safety in the trauma setting: a systematic review.

Background: Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population. Materials and methods: We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms "trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements." Results: The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis. Conclusions: Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.

Redefining "bowel regimen": Pharmacologic strategies and nutritional considerations in the management of small bowel fistulas.

Enterocutaneous fistulae (ECF) and enteroatmospheric fistulae (EAF) are difficult complications that primarily arise after abdominal surgical procedures. Development of an ECF or EAF carries significant mortality and morbidity. Effective management of patients with these disease states requires a multidisciplinary approach, which includes surgical, pharmacotherapeutic, and nutritional interventions. This review focuses on the medical and nutritional management of ECF/EAF, providing background on drug agents and nutritional strategies that may be helpful in reducing effluent volume, optimizing fistula healing, and maintaining nutritional health.

Minimizing opioid use after acute major trauma.

PURPOSE: Results of an initiative at an academic medical center to reduce prescription opioid use in patients with acute traumatic injuries are reported. METHODS: In 2014, the University of Kentucky Hospital trauma service implemented a pain management strategy consisting of patient and provider education emphasizing the use of nonopioid analgesics to minimize opioid use without compromising analgesia effectiveness. To assess the impact of the initiative, a retrospective analysis of data on cohorts of patients admitted with acute trauma before (n = 489) and after (n = 424) project implementation was conducted. The primary endpoint was opioid use (prescribed daily milligram morphine equivalents [MME]) at discharge. Secondary endpoints included inpatient opioid and alternative analgesic use, pain control, ileus development, length of stay, and discharge disposition. RESULTS: Compared with the preintervention cohort, the postintervention cohort had a lower median daily discharge MME overall (45 MME versus 90 MME, p < 0.001); after stratification of MME data by baseline opioid use, this finding held true only for patients with no opioid prescription at admission. Although utilization of gabapentinoids, skeletal muscle relaxants, and clonidine increased during the postintervention period, inpatient opioid use did not differ significantly in the 2 cohorts. Utilization of both nonsteroidal antiinflammatory drugs and acetaminophen was lower in the postintervention cohort versus the preintervention cohort. CONCLUSION: Targeted provider and patient education on minimizing opioid use was associated with a reduction in MME on discharge from the hospital after traumatic injury.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma.

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3-2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2-3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

In vitro transfusion of red blood cells results in decreased cytokine production by human T cells.

BACKGROUND: Transfusion-related immunomodulation consists of both proinflammatory and anti-inflammatory responses after transfusion of blood products. Stored red blood cells (RBCs) suppress human T-cell proliferation in vitro, but the mechanism remains unknown. We hypothesized that cytokine synthesis by T cells may be inhibited when stored RBCs are present and that suppression between fresh and stored RBCs would be different. METHODS: Purified human T cells were stimulated to proliferate with anti-CD3/anti-CD28 and then exposed to stored or fresh RBCs. Cells were placed in culture for 5 days. Cell culture supernatants were analyzed for the production of typical T-cell cytokines using multianalyte ELISArray kits. RESULTS: Stimulated T cells proliferated. RBC exposure markedly suppressed this proliferation. Interleukin 10, interleukin 17a, interferon γ, tumor necrosis factor α, and granulocyte macrophage colony-stimulating factor were increased in response to stimulation but depressed in the presence of stored RBCs. The use of fresh RBCs also resulted in depression of these cytokines when compared with stimulated T cells with no RBCs; however, this depression was less pronounced. CONCLUSION: T-cell activation is associated with both proinflammatory and anti-inflammatory cytokine release, comparable with patterns seen in trauma and acute injury. All of these responses are depressed by an exposure to stored RBCs. Decreased levels of these cytokines after RBC transfusion represents a potential contributor to the immunosuppressive complications seen in trauma patients after transfusion. This provides insight for future mechanistic studies to delineate the role of RBC transfusion in transfusion-related immunomodulation.

Morbid obesity and diverticulitis: results from the ACS NSQIP dataset.

BACKGROUND: We examined the relationship between morbid obesity, clinical presentation, and perioperative outcomes in patients offered surgery for diverticulitis. STUDY DESIGN: We queried the ACS NSQIP dataset from 2005 to 2010 for patients undergoing surgery for nonhemorrhaging diverticulitis. Univariate comparisons were made between normal weight (NL) and morbidly obese (MO) patients in terms of demographics, clinical presentation, and perioperative and postoperative outcomes variables using chi-square or rank tests. Multivariable regression was used to adjust for age in assessing the impact of MO on the likelihood of emergent surgery (ES), ostomy creation, open surgery, and undergoing procedures without an anastomosis. RESULTS: We identified 10,952 patients undergoing surgery for diverticulitis; morbidly obese (body mass index [BMI] ≥ 40 kg/m(2), n = 592, 5.7%), normal weight (BMI 18.5 to 25 kg/m(2), n = 2,530, 24.2%). Morbidly obese patients were younger than NL patients by an average of 9.4 years (p < 0.001). Morbidly obese patients underwent ES more frequently than NL patients (19.3% vs 15.4%; p = 0.025). Multivariable regression identified morbid obesity as an independent risk factor for ES (odds ratio [OR] 1.75, 95% CI 1.37 to 2.24, p < 0.001), ostomy creation (OR 1.67, 95% CI 1.34 to 2.08, p < 0.001), undergoing procedures without an anastomosis (OR 1.78, 95% CI 1.42 to 2.24, p < 0.001), and open surgery (OR 2.09, 95% CI 1.72 to 2.53, p < 0.001). Morbidly obese patients undergoing ES had more preoperative systemic inflammatory response syndrome/sepsis/septic shock than NL patients (72.8% vs 57.7%, p = 0.004). CONCLUSIONS: Morbidly obese patients undergoing surgery for diverticulitis are nearly 10 years younger than NL patients and are more likely to require ES, ostomy creation, open surgery, and to undergo procedures without an anastomosis. Morbidly obese patients undergoing ES also have more preoperative systemic inflammatory response syndrome/sepsis/septic shock.

y+ cationic amino acid transport of arginine in packed red blood cells.

BACKGROUND: Transfusion of packed red blood cells (PRBCs) is associated with morbidity and mortality. The mechanisms are not fully understood. Packed red blood cells deplete extracellular arginine and possess transporters for arginine, an amino acid essential for normal immunity. We hypothesize that the membrane y+ amino acid transporter contributes to arginine depletion in PRBCs. MATERIALS AND METHODS: We titrated PRBCs to a 10% hematocrit with phosphate-buffered saline, blocked PRBC y+ transporters using n-ethylmaleimide (0.2 mM), and measured arginine and ornithine levels using liquid chromatography-mass spectroscopy. We added radiolabeled L-arginine [4,5-(3)H] (10 µmol/L) added to similar culture conditions and measured arginine uptake in counts per minute (CPM). We examined storage periods of 6-9 d, 1-4 wk, and 6 wk, and correlated donor demographics with arginine uptake. RESULTS: n-Ethylmaleimide blockade of y+ transporters impaired PRBC arginine depletion from culture media (117.6 ± 8.6 µM versus 76.9 ± 5.8 µM; P < 0.001) and reduced intracellular L-arginine (7,574 ± 955 CPM versus 18,192 ± 1,376 CPM; P < 0.01). Arginine depletion increased with storage duration (1 wk versus 6 wk; P < 0.002). With n-ethylmaleimide treatment, 6-wk-old PRBCs preserved more culture arginine (P < 0.008) than at shorter durations. Nine-day storage duration increased L-arginine uptake compared with 6- to 8-day storage (n = 77, R = 0.225, P < 0.05). Extracellular arginine depletion and extracellular ornithine synthesis varied among donors and correlated inversely (R = -0.5, P = 0.01). CONCLUSIONS: Membrane y+ transporters are responsible for arginine depletion by PRBCs. Membrane y+ activity increases with storage duration. Arginine uptake varies among donors. Membrane biology of RBCs may have a role in the negative clinical effects associated with PRBC transfusion.

An acute care surgery service generates a positive contribution margin in an appropriately staffed hospital.

BACKGROUND: Acute care surgery (ACS) includes trauma, surgical critical care, and emergent general surgery. There is a national shortage of institutions that can provide for patients needing access to emergency surgical care. Inability to fund ACS surgeons can be a barrier. We hypothesize that an ACS service, in an appropriately staffed hospital, generates a positive contribution margin (CM). STUDY DESIGN: Fiscal data for 2009 were retrospectively reviewed at the University of Kentucky, a Level I trauma center with an ACS service. Contribution margin (ie, net revenue minus direct costs) and mean length of stay were calculated for all patients admitted to the ACS service. Inpatient data were stratified by trauma vs general surgery, emergent vs elective, and by payor mix. RESULTS: Annual CM associated with the 5 ACS faculty was $21,799,000. Trauma generated higher CM than general surgery. General surgery had a greater CM, more if emergent than if elective ($9,500 vs $5,500; p < 0.01). Self-payment was lower with emergent general surgery vs trauma (20% vs 25%; p = 0.02). CONCLUSIONS: Acute care surgery generates a positive CM. Emergent general surgery generates a greater CM than elective general surgery because of increased case mix index. These data suggest that hospital subsidization of acute care surgeons is financially feasible and might address the surgical workforce shortage and the critical problem of access to emergency surgical services.

An acute care surgery rotation contributes significant general surgical operative volume to residency training compared with other rotations.

BACKGROUND: Surgical resident rotations on trauma services are criticized for little operative experience and heavy workloads. This has resulted in diminished interest in trauma surgery among surgical residents. Acute care surgery (ACS) combines trauma and emergency/elective general surgery, enhancing operative volume and balancing operative and nonoperative effort. We hypothesize that a mature ACS service provides significant operative experience. METHODS: A retrospective review was performed of ACGME case logs of 14 graduates from a major, academic, Level I trauma center program during a 3-year period. Residency Review Committee index case volumes during the fourth and fifth years of postgraduate training (PGY-4 and PGY-5) ACS rotations were compared with other service rotations: in total and per resident week on service. RESULTS: Ten thousand six hundred fifty-four cases were analyzed for 14 graduates. Mean cases per resident was 432 ± 57 in PGY-4, 330 ± 40 in PGY-5, and 761 ± 67 for both years combined. Mean case volume on ACS for both years was 273 ± 44, which represented 35.8% (273 of 761) of the total experience and exceeded all other services. Residents averaged 8.9 cases per week on the ACS service, which exceeded all other services except private general surgery, gastrointestinal/minimally invasive surgery, and pediatric surgery rotations. Disproportionately more head/neck, small and large intestine, gastric, spleen, laparotomy, and hernia cases occurred on ACS than on other services. CONCLUSIONS: Residents gain a large operative experience on ACS. An ACS model is viable in training, provides valuable operative experience, and should not be considered a drain on resident effort. Valuable ACS rotation experiences as a resident may encourage graduates to pursue ACS as a career.

Plank fence penetration into automobiles-implications for prevention initiatives.

The wooden plank fence presents a deadly but unrecognized hazard to motorists. We hypothesize that fence plank injury is prevalent and results in significant morbidity and mortality. Databases of the University of Kentucky's Level I Trauma Center and the Fayette County Coroner were retrospectively analyzed over a 12-year period (1995-2006). One hundred and twenty-eight subjects were involved in vehicle contact with wooden plank fences. One hundred and twenty-three subjects were evaluated at the Emergency Department of our trauma center; 35 (27%) had a patient-plank interaction (PPI). Men (30/35) were more frequently involved (86%), and average age was 32.8 years. Thirty-two (91%) were drivers; 14/35 (40%) died from PPI-related injuries. The most common cause of death was blunt head trauma in 13 of these 14 fatally injured subjects (93%). This study provides new data underscoring the frequency, lethality, and economic consequences of this injury mechanism. Further research is needed to quantify the national prevalence of this problem and develop injury-mitigating strategies pertaining to roadway or fence design.

General surgical operative duration is associated with increased risk-adjusted infectious complication rates and length of hospital stay.

BACKGROUND: Studies of specific procedures have shown increases in infectious complications with operative duration. We hypothesized that operative duration is independently associated with increased risk-adjusted infectious complication (IC) rates in a broad range of general surgical procedures. STUDY DESIGN: We queried the American College of Surgeons National Surgical Quality Improvement Program database for general surgical operations performed from 2005 to 2007. ICs (wound infection, sepsis, urinary tract infection, and/or pneumonia) and length of hospital stay (LOS) were evaluated versus operative duration (OD, ie, incision to closure). Multivariable regression adjusted for 38 patient risk variables, operation type and complexity, wound class and intraoperative transfusion. We also analyzed isolated laparoscopic cholecystectomies in patients of American Society of Anesthesiologists class 1 or 2, without intraoperative transfusion and with a clean or clean-contaminated wound class. RESULTS: In 299,359 operations performed at 173 hospitals, unadjusted IC rates increased linearly with OD at a rate of close to 2.5% per half hour (chi-square test for linear trend, p < 0.001). After adjustment, IC risk increased for each half hour of OD relative to cases lasting

Strangulated appendix after transabdominal preperitoneal (TAPP) inguinal hernia repair.

INTRODUCTION: Laparoscopic inguinal hernia repair can be performed totally extraperitoneal or transabdominal preperitoneal (TAPP). Both repairs are associated with mesh-related complications. This is the first report of a mesh-strangulated appendix, with subsequent necrosis and perforation, after TAPP inguinal hernia repair. CASE: A 48-year-old male, 10-years status post-bilateral TAPP inguinal hernia repair presented with acute right groin bulge, pain, nausea, emesis, and fever. He was found to have a large, tender, nonreducible right groin mass. He was taken to the operating room for right groin exploration and found to have gross purulent material but no evidence of a recurrent hernia. A laparoscope was inserted into the abdomen where the appendix was found strangulated between the mesh and the transversalis fascia. CONCLUSIONS: Mesh-related complications after TAPP inguinal hernia repair are rare. This is the first report of a strangulated appendix secondary to mesh entrapment after TAPP repair.