Inferior Epigastric Artery Pseudoaneurysm Following Laparoscopic Appendectomy.

An inferior epigastric artery pseudoaneurysm is an exceptionally rare occurrence. Formation of an inferior epigastric artery pseudoaneurysm can be seen following surgical intervention and is more common after laparoscopy. A sixty-eight-year-old male presented with a right upper quadrant bulge at his incision site two months following laparoscopic appendectomy. The patient reported sudden onset of a non-reducible bulge at a 5 mm trocar incision site with minimal pain and without obstructive symptoms. Computed tomography of his abdomen and pelvis with intravenous contrast revealed a 4.2 cm pseudoaneurysm with peripheral thrombosis within the right inferior epigastric artery. The patient subsequently underwent open exploration with the evacuation of pseudoaneurysm thrombus and ligation of arteriovenous fistula. The patient recovered well without complication from pseudoaneurysm. Inferior epigastric artery pseudoaneurysm following any laparoscopic procedure is rare. This case highlights the importance of understanding the abdominal wall anatomy and its vascular supply to avoid such injury. We present this case to bring light to this rare occurrence and to highlight the importance of proper trocar placement during any laparoscopic procedure.

Rare Rupture of Small 4.3 cm Abdominal Aortic Aneurysm.

Abdominal aortic aneurysm (AAA) is a common medical condition with the feared, and often fatal, complication of rupture. The risk of rupture has been well documented to correlate with aneurysm size. It is exceedingly rare for an AAA less than 5 cm to rupture. This case report demonstrates an asymptomatic 4.3 cm AAA that ruptured while admitted to the hospital with COVID-19 pneumonia. The patient was successfully managed with an endovascular aortoiliac stent graft. Although rare, in patients with small AAA, rupture must remain in the differential diagnosis in the setting of acute onset abdominal or back pain. Furthermore, when quickly recognized, these patients can be safely managed with an endovascular approach.

Teaching Small Bite Fascial Closure Technique: Improved Accuracy and Consistency Through Simulation.

Despite evidence that small bite closure is beneficial, it is not well documented how accurately and consistently surgeons employ this technique. We created a felt model to simulate fascial closure and educate residents regarding small bites. This study aims to gauge accuracy and consistency of bite size in fascial closure and assess if utilizing a templated model could improve technique. Two 10 cm incisions were made in different pieces of felt. Residents were instructed to suture the incisions to simulate fascial closure by running the incisions closed with 1 cm and 5 mm bites respectively. The process was repeated with templated pieces of felt marking 1 and 0.5 cm to guide bite size. Residents were timed for each closure. The travel and distance from the midline for each bite was measured and analysis performed. 14 residents participated. Paired T-test compared means and standard deviations of bite size. Taking 5 mm bites took more time. Standard deviation of travel and right sided distance from midline were significantly smaller when a template was utilized. Standard deviation of travel as well as right sided distance was also improved when instructed to take 5 mm bites. This study demonstrates that a small bite technique results more closure and that when residents are instructed to take smaller bites. The adage, "aim small, miss small," holds true in fascial closure and may be one reason why small bites improve hernia rates. This study also suggests that the use of a template improves accuracy and consistency of closure regardless of bite size intention.

Situations That Preclude Routine Intraoperative Cholangiography.

Intraoperative cholangiogram (IOC) is a useful tool for surgeons to assess anatomy of the biliary tree and diagnose biliary pathology. Many surgeons utilize cholangiography in most cases in hopes of preventing ductal injuries and are deemed routine cholangiographers. There is little data on the success rate and reasons why IOC is not performed. The purpose of this study was to evaluate the use of routine cholangiography and to determine reasons why cholangiography was not performed. 693 cholecystectomies were analyzed. Intraoperative cholangiogram was attempted in 553 (79.8%) of these cases. The success rate of performing cholangiograms in those attempted was 93.3%. Intraoperative cholangiogram was not attempted in 140 patients (20.2%) for various reasons. Although many surgeons consider themselves routine cholangiographers, there are times when IOC is not feasible. Knowledge of these reasons may help clarify indications for IOC. For most cases, routine cholangiography appears to be feasible.

The Hernia Coding Conundrum: A Potential Benefit of the International Hernia Collaboration Online Social Media Platform.

BACKGROUND: Despite various resources on the subject, there remain questions regarding billing and coding hernia surgery. Recently, social media has been used to disseminate information in about surgery. The purpose of this project is to evaluate posts relating to coding through one online social media platform. MATERIALS AND METHODS: The International Hernia Collaboration Facebook site was queried with terms relating to coding. Inclusion criteria were post discussing coding on the site. Posts relating to coding were reviewed by at least 2 reviewers. Number of comments, main topic of question, and additional information about codes were recorded and descriptive statistics generated. RESULTS: There were 100 posts found using the search term coding of which 85 met inclusion criteria. Post ranged from 5/2014 to 6/2021. Posts were from 72 surgeons with an average of 12 responses per post. Posts most commonly related to ventral and incisional hernia (53) followed by inguinal (18), other (19), diaphragm (4), and inguinal/ventral (1). For the ventral/incisional hernia, the most common posts were related to myofascial release techniques (29) followed by mesh (6), botox (5), hernia prevention (3), other (3), robotic surgery (2), open surgery (2), rectus diastasis (2), and laparoscopy (2). DISCUSSION: There remains controversies over coding for hernia repair particularly myofascial releases in ventral and incisional and new techniques using the robot. An online social media platform appears to be a viable way to disseminate coding information and generate discussion. Further study is needed to evaluate the role of social media for coding.

The T-Line® Hernia Mesh, A Novel Mesh Uniquely Designed to Prevent Hernia Recurrence and Occurrence.

Ventral hernia repair (VHR) fixation techniques with current meshes on the market are prone to failure from intra-abdominal pressure spikes due to coughing or lifting, for example. The T-Line® Hernia Mesh (Deep Blue Medical Advances, Durham, North Carolina) is a new mesh with a novel fixation mechanism to enhance anchoring strength addressing hernia occurrence and recurrence. Used similarly to traditional mesh, the new mesh uses incorporated mesh sutures that are 15 times the surface area of sutures for fixation rather than monofilament sutures, providing ~275% stronger anchoring strength. The increased surface area of the mesh extensions decreases tension on the mesh and tissue and increases the strength of the repair overall. There is also the likelihood that anchoring gains strength over time as the extensions undergo bioincorporation. This novel mesh specifically addresses the most common complication of VHR and has the potential to significantly improve outcomes.

Decreasing Incisional Hernia by Teaching 4:1 Suture to Wound Length Ratio Early in Surgical Education.

OBJECTIVE: Incisional hernia formation has become a major burden for our healthcare system. One factor that has been shown to reduce incisional hernia rates that can be impacted on by the surgeon is the ability to achieve a 4:1 suture to wound length ratio. The purpose of this study is to evaluate whether a focused educational program for surgical residents can help improve laparotomy closures and be successful in achieving 4:1 suture to wound length ratios. DESIGN: Following Institutional Review Board approval, consecutive abdominal wall closures were reviewed from December 2013 to July 2016. S:W length ratios were calculated in all cases and after 100 cases a formal audit of success and risk factors for not achieving a 4:1 ratio was performed followed by a formal resident education on laparotomy closure. The ability to achieve a 4:1 ratio for the first 100 cases following resident education was then compared to the 100 patients preceding the education with a p-value of <0.05 considered significant. RESULTS: Two hundred patients underwent midline laparotomy with S:W length ratio calculated. In the first 100 patients, 76% of patients received a 4:1 S:W closure. Following resident education, this improved to 90% in the second 100 patients (p = 0.0083). Among patients where 2 residents performed the abdominal closure, 50% got an adequate 4:1 closure. This improved to 92% for the second 100 patients (p = 0.016). CONCLUSION: A 4:1 S:W length ratio is a simple technique that has been proven to decrease incisional hernia. It requires no additional cost and can easily be implemented into practice. The act of formal resident education and measuring suture tails to calculate a S:W ratio on each case holds surgeons accountable and improves success rate of achieving a 4:1 ratio.

Evaluation of Absorbable Mesh for Prophylactic Mesh Augmentation in High-Risk Patients.

PURPOSE: Hernia prevention following abdominal surgery has become a subject of growing interest in general surgery. Prophylactic mesh augmentation (PMA) is an emerging technique to prevent incisional hernia in high-risk populations. The aim of this study was to determine the efficacy and safety of PMA using an absorbable mesh. METHODS: A retrospective review was performed on patients who underwent PMA between July 2014 and March 2020. A prophylactic synthetic absorbable mesh (Phasix™; Becton Dickinson, Franklin Lakes, NJ) was placed at the surgeon's discretion according to the indication for the primary operation. The primary outcome was the incisional hernia rate. Secondary outcomes included mesh-related or other complications. RESULTS: Fifty patients underwent PMA following cystectomy with ileal conduit, open aortic surgery, or colostomy creation/takedown. Overall, 10 patients (20%) developed hernia at a median follow-up of 2.2 years. Six of these 10 hernias occurred at incisions where mesh was not placed. There were no documented mesh infections. One mesh (2%) in the AAA group was explanted due to an infected endograft, but there was no evidence of mesh complication. Two patients (4%) developed seroma. Two (4%) patients developed superficial surgical site infections (SSI). There were no documented deep-space SSI. CONCLUSION: PMA is an emerging technique with a low rate of incisional hernia in high-risk patients, such as those undergoing stoma creation or open aortic intervention. The use of an absorbable mesh seems promising, however more and longer-term research is needed.