Better stoma care using the Stoma App: does it help? A first randomized double-blind clinical trial on the effect of mobile healthcare on quality of life in stoma patients.

BACKGROUND: Receiving a stoma significantly impacts patients' quality of life. Coping with this new situation can be difficult, which may result in a variety of physical and psychosocial problems. It is essential to provide adequate guidance to help patients cope with their stoma, as this positively influences self-efficacy in return. Higher self-efficacy reduces psychosocial problems increasing patient's quality of life. This study investigates whether a new mobile application, the Stoma App, improves quality of life. And if personalized guidance, timed support, and peer contact offered as an in-app surplus makes a difference. METHODS: A double-blind, randomized controlled trial was conducted between March 2021 and April 2023. Patients aged > 18 years undergoing ileostomy or colostomy surgery, in possession of a compatible smartphone were included. The intervention group received the full version of the app containing personalized and time guidance, peer support, and generic (non-personalized) stoma-related information. The control group received a restricted version with only generic information. Primary outcome was stoma quality of life. Secondary outcomes included psychological adaption, complications, re-admittance, reoperations, and length of hospital stay. RESULTS: The intervention version of the app was used by 96 patients and the control version by 112 patients. After correction for confounding, the intervention group reported a significant 3.1-point improvement in stoma-related quality of life one month postoperatively (p = 0.038). On secondary outcomes, no significant improvements could be retrieved of the intervention group. CONCLUSION: The Stoma App improves the quality of life of stoma patients. Peer support and personalized guidance are of significant importance in building self-efficacy. It is to be recommended to implement Stoma app-freely available software qualifying as a medical device-in standard stoma care pathways for the benefits of both patients and healthcare providers.

Prophylactic Mesh Placement During Formation of an End-colostomy: Long-term Randomized Controlled Trial on Effectiveness and Safety.

OBJECTIVE: The aim of this study was to determine if prophylactic mesh placement is an effective, safe, and cost-effective procedure to prevent parastomal hernia (PSH) formation in the long term. BACKGROUND: A PSH is the most frequent complication after stoma formation. Prophylactic placement of a mesh has been suggested to prevent PSH, but long-term evidence to support this approach is scarce. METHODS: In this multicentre superiority trial patients undergoing the formation of a permanent colostomy were randomly assigned to either retromuscular polypropylene mesh reinforcement or conventional colostomy formation. Primary endpoint was the incidence of a PSH after 5 years. Secondary endpoints were morbidity, mortality, quality of life, and cost-effectiveness. RESULTS: A total of 150 patients were randomly assigned to the mesh group (n = 72) or nonmesh group (n = 78). For the long-term follow-up, 113 patients were analyzed, and 37 patients were lost to follow-up. After a median follow-up of 60 months (interquartile range: 48.6-64.4), 49 patients developed a PSH, 20 (27.8%) in the mesh group and 29 (37.2%) in the nonmesh group ( P = 0.22; RD: -9.4%; 95% CI: -24, 5.5). The cost related to the meshing strategy was € 2.239 lower than the nonmesh strategy (95% CI: 491.18, 3985.49), and quality-adjusted life years did not differ significantly between groups ( P = 0.959; 95% CI: -0.066, 0.070). CONCLUSIONS: Prophylactic mesh placement during the formation of an end-colostomy is a safe procedure but does not reduce the incidence of PSH after 5 years of follow-up. It does, however, delay the onset of PSH without a significant difference in morbidity, mortality, or quality of life, and seems to be cost-effective.

The association of potential prognostic determinants to nonadherence to negative pressure wound therapy: An exploratory prospective prognostic study.

BACKGROUND: Up to now it is unclear which determinants influence nonadherence to negative pressure wound therapy. This study aimed to assess the predictive value of prognostic determinants to nonadherence to negative pressure wound therapy. METHODS: A multicenter prospective cohort study on patients with wounds treated with negative pressure wound therapy. Data of 25 potential prognostic determinants of nonadherence were collected using a web-based case record form. Primary outcome was nonadherence to negative pressure wound therapy, defined as premature termination on request of the patient. Logistic regression analyses were used to explore the association between the potential determinants and nonadherence. RESULTS: Nonadherence to negative pressure wound therapy was found in 32 out of 264 patients (12.1%). Univariable analyses identified 6 candidate prognostic determinants: having sensitive skin (odds ratio 2.32, 95% confidence interval 1.10-5.10, P = .03), decision for negative pressure wound therapy made as a shared decision (odds ratio 2.43, 95% confidence interval 1.06-6.30, P = .05), handiness technique (odds ratio 1.80, 95% confidence interval 0.86-3.89, P = .13), alternatives discussed (odds ratio 1.78, 95% confidence interval 0.83-3.75, P = .13), knowledge and understanding negative pressure wound therapy (odds ratio 0.50, 95% confidence interval 0.18-1.20, P = .15), and previous experience with negative pressure wound therapy (odds ratio 0.42, 95% confidence interval 0.10-1.24, P = .17). In the multivariable analysis, only having sensitive skin appeared to be significant (odds ratio 2.20, 95% confidence interval 1.02-4.85, P = .05). CONCLUSION: Patients who have sensitive skin may have an increased risk of premature termination of negative pressure wound therapy. Further research is warranted to determine which strategies are successful to overcome skin irritation problems to avoid nonadherence to negative pressure wound therapy.

LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

OBJECTIVE: To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery. SUMMARY BACKGROUND DATA: Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological. METHODS: A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL. RESULTS: There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL. CONCLUSIONS: This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital.

Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7 days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90 days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.

Which determinants are considered to be important for adherence to Negative Pressure Wound Therapy: A multimethods study.

AIM: To explore the extent of patients that choose to cease Negative Pressure Wound Therapy (NPWT) prematurely in a clinical setting, and to explore the determinants of nonadherence. METHOD: This study exists out of: (1) a retrospective study to assess the number of patients who ceased NPWT prematurely; (2) a narrative review (NR) to identify determinants of nonadherence; and (3) a survey among wound care specialists to explore specific determinants of nonadherence to NPWT. RESULTS: (1) Based on the retrospective study, 20% ceased NPWT prematurely because of experienced limitations in daily activities. (2) Based on 22 studies, 23 determinants that might influence nonadherence were identified and added as questions in the survey. (3) Twenty-two percent (n = 136) wound care specialists completed the survey. Confidence with the healthcare team, consistency in therapy advices, coping with pain, former negative experiences with NPWT, a normal activity pattern, social support from family or friends, and support from the healthcare team were identified as highly relevant determinants of nonadherence to NPWT. Only religion scored distinctively lower. CONCLUSION: This study is a first step in exploring the determinants of nonadherence to NPWT. In 20% NPWT was prematurely ceased at the request of the patient, this means that this therapy may have not been the best choice of therapy for this particular patient. The identification of potential determinants of nonadherence may help healthcare professionals in their dialogue with patients. The next step should be a prognostic study to assess which determinants best predict adherence to NPWT.

Outcomes of a new slowly resorbable biosynthetic mesh (Phasix™) in potentially contaminated incisional hernias: A prospective, multi-center, single-arm trial.

BACKGROUND: Resorbable biomaterials have been developed to reduce the amount of foreign material remaining in the body after hernia repair over the long-term. However, on the short-term, these resorbable materials should render acceptable results with regard to complications, infections, and reoperations to be considered for repair. Additionally, the rate of resorption should not be any faster than collagen deposition and maturation; leading to early hernia recurrence. Therefore, the objective of this study was to collect data on the short-term performance of a new resorbable biosynthetic mesh (Phasix™) in patients requiring Ventral Hernia Working Group (VHWG) Grade 3 midline incisional hernia repair. MATERIALS AND METHODS: A prospective, multi-center, single-arm trial was conducted at surgical departments in 15 hospitals across Europe. Patients aged ≥18, scheduled to undergo elective Ventral Hernia Working Group Grade 3 hernia repair of a hernia larger than 10 cm2 were included. Hernia repair was performed with Phasix™ Mesh in sublay position when achievable. The primary outcome was the rate of surgical site occurrence (SSO), including infections, that required intervention until 3 months after repair. RESULTS: In total, 84 patients were treated with Phasix™ Mesh. Twenty-two patients (26.2%) developed 32 surgical site occurrences. These included 11 surgical site infections, 9 wound dehiscences, 7 seromas, 2 hematomas, 2 skin necroses, and 1 fistula. No significant differences in surgical site occurrence development were found between groups repaired with or without component separation technique, and between clean-contaminated or contaminated wound sites. At three months, there were no hernia recurrences. CONCLUSION: Phasix™ Mesh demonstrated acceptable postoperative surgical site occurrence rates in patients with a Ventral Hernia Working Group Grade 3 hernia. Longer follow-up is needed to evaluate the recurrence rate and the effects on quality of life. This study is ongoing through 24 months of follow-up.

Can Electric Nose Breath Analysis Identify Abdominal Wall Hernia Recurrence and Aortic Aneurysms? A Proof-of-Concept Study.

Introduction. This pilot study evaluates if an electronic nose (eNose) can distinguish patients at risk for recurrent hernia formation and aortic aneurysm patients from healthy controls based on volatile organic compound analysis in exhaled air. Both hernia recurrence and aortic aneurysm are linked to impaired collagen metabolism. If patients at risk for hernia recurrence and aortic aneurysms can be identified in a reliable, low-cost, noninvasive manner, it would greatly enhance preventive options such as prophylactic mesh placement after abdominal surgery. Methods. From February to July 2017, a 3-armed proof-of-concept study was conducted at 3 hospitals including 3 groups of patients (recurrent ventral hernia, aortic aneurysm, and healthy controls). Patients were measured once at the outpatient clinic using an eNose with 3 metal-oxide sensors. A total of 64 patients (hernia, n = 29; aneurysm, n = 35) and 37 controls were included. Data were analyzed by an automated neural network, a type of self-learning software to distinguish patients from controls. Results. Receiver operating curves showed that the automated neural network was able to differentiate between recurrent hernia patients and controls (area under the curve 0.74, sensitivity 0.79, and specificity 0.65) as well as between aortic aneurysm patients and healthy controls (area under the curve 0.84, sensitivity 0.83, and specificity of 0.81). Conclusion. This pilot study shows that the eNose can distinguish patients at risk for recurrent hernia and aortic aneurysm formation from healthy controls.

Negative pressure wound therapy for patients with hard-to-heal wounds: a systematic review.

OBJECTIVE: Despite the lack of evidence, negative pressure wound therapy (NPWT) is commonly used in patients with hard-to-heal wounds. In our medical centre, one third of patients with abdominal wounds infected postoperatively end this therapy prematurely due to negative experiences and prefer standard wound care. This study was designed to explore the effects of NPWT on quality of life (QoL). METHOD: A search from 2000 to 2019 in eight databases was performed to identify qualitative studies of patients treated with NPWT. Studies were selected by two independent reviewers, who appraised the methodological quality, extracted and structured the data and performed content analysis. RESULTS: A total of five qualitative studies with good methodological quality, incorporating 51 individual patients, were included. After content analysis, four major themes emerged: reduced freedom of movement caused by an electric device; decreased self-esteem; increased social and professional dependency; and gaining self-control. CONCLUSION: NPWT has major effects on the physical, psychological and social domains of QoL. Knowledge of these effects may lead to improved treatment decisions for patients with hard-to-heal wounds regarding use of NPWT or standard wound care.

Perioperative lipid-enriched enteral nutrition versus standard care in patients undergoing elective colorectal surgery (SANICS II): a multicentre, double-blind, randomised controlled trial.

BACKGROUND: Postoperative ileus and anastomotic leakage severely impair recovery after colorectal resection. We investigated the effect of perioperative lipid-enriched enteral nutrition versus standard care on the risk of postoperative ileus, anastomotic leakage, and other clinical outcomes. METHODS: We did an international, multicentre, double-blind, randomised, controlled trial of patients (≥18 years) undergoing elective colorectal surgery with primary anastomosis at six clinical centres in the Netherlands and Denmark. Patients were randomly assigned (1:1), stratified by location (colonic and rectal) and type of surgery (laparoscopic and open), via online randomisation software, with block sizes of six, to receive either continuous lipid-enriched enteral tube feeding from 3 h before until 6 h after surgery (intervention) or no perioperative nutrition (control). Surgeons, patients, and researchers were masked to treatment allocation for the entire study period. The primary outcome was postoperative ileus. Secondary outcomes included anastomotic leakage, pneumonia, preoperative gastric volumes, time to functional recovery, length of hospital stay, the need for additional interventions, intensive care unit admission, postoperative inflammatory response, and surgical complications. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02175979, and trialregister.nl, number NTR4670. FINDINGS: Between July 28, 2014, and February 20, 2017, 280 patients were randomly assigned, 15 of whom were excluded after random allocation because they fulfilled one or more exclusion criteria. 265 patients received perioperative nutrition (n=132) or standard care (n=133) and were included in the analyses. A postoperative ileus occurred in 37 (28%) patients in the intervention group versus 29 (22%) in the control group (risk ratio [RR] 1·09, 95% CI 0·95-1·25; p=0·24). Anastomotic leakage occurred in 12 (9%) patients in the intervention group versus 11 (8%) in the control group (RR 1·01, 95% CI 0·94-1·09; p=0·81). Pneumonia occurred in ten (8%) patients in the intervention group versus three (2%) in the control group (RR 1·06, 95% CI 1·00-1·12; p=0·051). All other secondary outcomes were similar between groups (all p>0·05). INTERPRETATION: Perioperative lipid-enriched enteral nutrition in patients undergoing elective colorectal surgery has no advantage over standard care in terms of postoperative complications. FUNDING: Netherlands Organisation for Health Research and Development (ZonMW), Fonds NutsOhra, and Danone Research.

The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study.

BACKGROUND: Medical care for admitted patients in hospitals is increasingly reallocated to physician assistants (PAs). There is limited evidence about the consequences for the quality and safety of care. This study aimed to determine the effects of substitution of inpatient care from medical doctors (MDs) to PAs on patients' length of stay (LOS), quality and safety of care, and patient experiences with the provided care. METHODS: In a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model). Thirty-four wards were recruited across the Netherlands. Patients were followed from admission till one month after discharge. Primary outcome measure was patients' LOS. Secondary outcomes concerned eleven indicators for quality and safety of inpatient care and patients' experiences with the provided care. RESULTS: Data on 2,307 patients from 34 hospital wards was available. The involvement of PAs was not significantly associated with LOS (ß 1.20, 95%CI 0.99-1.40, p = .062). None of the indicators for quality and safety of care were different between study arms. However, the involvement of PAs was associated with better experiences of patients (ß 0.49, 95% CI 0.22-0.76, p = .001). CONCLUSIONS: This study did not find differences regarding LOS and quality of care between wards on which PAs, in collaboration with MDs, provided medical care for the admitted patients, and wards on which only MDs provided medical care. Employing PAs seems to be safe and seems to lead to better patient experiences. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01835444.

The general surgeon's perspective of rectus diastasis. A systematic review of treatment options.

BACKGROUND: Diastasis of the rectus abdominis muscles (DRAM) is characterised by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This causes the midline to "bulge" when intra-abdominal pressure is increased. Plastic surgery treatment for DRAM has been thoroughly evaluated, though general surgical treatments and the efficacy of physiotherapy remain elusive. The aim of this systematic literature review is to evaluate both general surgical and physiotherapeutic treatment options for restoring DRAM in terms of postoperative complications, patient satisfaction, and recurrence rates. METHOD: MEDLINE®, Embase, PubMed, PubMed Central®, The cochrane central registry of controlled trials (CENTRAL), Google Scholar, and the Physiotherapy Evidence Database (PEDro) were searched using the following terms: 'rectus diastasis', 'diastasis recti', 'midline', and 'abdominal wall'. All clinical studies concerning general surgical or physiotherapeutic treatment of DRAM were eligible for inclusion. RESULT: Twenty articles describing 1.691 patients (1.591 surgery/100 physiotherapy) were included. Surgical interventions were classified as plication techniques (313 patients; 254 open/59 laparoscopic), modified hernia repair techniques (68 patients, all open), and combined hernia & DRAM techniques (1.210 patients; 1.149 open/40 hybrid). The overall methodological quality was low. Plication techniques with interrupted sutures and mesh reinforcement were applied most frequently for DRAM repair. Open repairs were performed in 85% of patients. There was no difference in postoperative complications or recurrence rate after laparoscopic or open procedures, or between plication and modified hernia repair techniques. Physiotherapy programmes were unable to reduce IRD in a relaxed state. Though reduction of IRD during muscle contraction was described. CONCLUSION: Both plication-based methods and hernia repair methods are used for DRAM repair. Based on the current literature, no clear distinction in recurrence rate, postoperative complications, or patient reported outcomes can be made. Complete resolution of DRAM, measured in a relaxed state, following a physiotherapy training programme is not described in current literature. Physiotherapy can achieve a limited reduction in IRD during muscle contraction, though the impact of this finding on patient satisfaction, cosmesis, or function outcome is unclear.

Impact of hernia volume on pulmonary complications following complex hernia repair.

BACKGROUND: Despite a multitude of evidence-based prediction models and risk factors for postoperative complications after ventral hernia repair, estimating a patient's risk of postoperative complications after ventral hernia repair remains challenging. In an attempt to improve the preoperative assessment of complex hernia patients, some studies have examined pulmonary changes after hernia repair hypothesizing that large hernias lead to pulmonary changes and increased pulmonary complication rates. Some studies have described a correlation between hernia volume and pulmonary changes, although none provided compelling evidence to identify hernia volume as a risk factor for pulmonary complications. This study evaluates the relationship between hernia volume and postoperative pulmonary complications using computed tomography (CT)-based volume measurements. MATERIALS AND METHODS: Analysis of a prospectively maintained database of consecutive complex hernia patients from 2011 to 2014 undergoing endoscopic (ECST) or open component separation technique (CST) for a hernia defect with a minimum width of 6 cm and visual protrusion of the hernia sac ventral of the rectus abdominis muscles in supine position was performed. Hernia volume was calculated using multiple plane reconstruction of a standard abdominal CT-scan. Noted endpoints were pulmonary complications. RESULTS: Thirty-five patients underwent ECST (n = 20) or CST (n = 15) with a median defect volume of 474 cm3 (range, 114-2086 cm3). Observed complications were pneumonia (n = 4), pulmonary infiltrate (n = 3), aspiration pneumonia (n = 2), and acute respiratory distress syndrome (n = 1). Univariate and multivariate analyses showed that pulmonary complications were associated with "hernia volume" (P = 0.045; 95% CI: 1.008-1.910). CONCLUSIONS: Hernia volume is a promising risk factor for postoperative pulmonary complications and can be calculated using a standard abdominal CT-scan.

Prophylactic Mesh Placement During Formation of an End-colostomy Reduces the Rate of Parastomal Hernia: Short-term Results of the Dutch PREVENT-trial.

OBJECTIVE: The aim of this study was to investigate the incidence of parastomal hernias (PSHs) after end-colostomy formation using a polypropylene mesh in a randomized controlled trial versus conventional colostomy formation. BACKGROUND: A PSH is the most frequent complication after stoma formation. Symptoms may range from mild abdominal pain to life-threatening obstruction and strangulation. The treatment of a PSH is notoriously difficult and recurrences up to 20% have been reported despite the use of mesh. This has moved surgical focus toward prevention. METHODS: Augmentation of the abdominal wall with a retro-muscular lightweight polypropylene mesh was compared with the traditional formation of a colostomy. In total, 150 patients (1:1 ratio) were included. The incidence of a PSH, morbidity, mortality, quality of life, and cost-effectiveness was measured after 1 year of follow-up. RESULTS: There was no difference between groups regarding demographics and predisposing factors for PSH. Three out of 67 patients (4.5%) in the mesh group and 16 out of 66 patients (24.2%) in the nonmesh group developed a PSH (P = 0.0011). No statistically significant difference was found in infections, concomitant hernias, SF-36 questionnaire, Von Korff pain score, and cost-effectiveness between both study groups. CONCLUSION: Prophylactic augmentation of the abdominal wall with a retromuscular lightweight polypropylene mesh at the ostomy site significantly reduces the incidence of PSH without a significant difference in morbidity, mortality, quality of life, or cost-effectiveness.

A gallbladder torsion presenting as acute cholecystitis in an elderly woman: A case report.

INTRODUCTION: Gallbladder torsion is a rare, but potentially lethal disease, in which early recognition is crucial. CASE PRESENTATION: We describe the case of an 89-year-old Caucasian woman who presented with clinical symptoms suggestive of acute cholecystitis to our hospital. Radiological imaging confirmed our clinical diagnosis. At first we considered percutaneous gallbladder drainage because of her age and comorbidity, but instead performed laparoscopic cholecystectomy because of rapid clinical deterioration. During laparoscopy a necrotic gallbladder due to torsion of the gallbladder around the cystic duct was found. CONCLUSION: Because percutaneous drainage could lead to further deterioration in the case of gallbladder torsion, this rare condition should be considered before performing a percutaneous drainage of cholecystitis.

Interposition of polyglactin mesh does not prevent adhesion formation between viscera and polypropylene mesh.

BACKGROUND: The use of intra-peritoneal polypropylene mesh (PPM) to repair incisional hernia carries the risk of adhesions and damage to the intra-abdominal viscera. Polyglactin 910 mesh (PGM) is advocated to avoid contact between PPM and the intra-abdominal viscera. An experimental study in rats was performed to determine if interposition of a resorbable prosthesis between the PPM and viscera alters biocompatibility, adhesion formation, and herniation. MATERIALS AND METHODS: A 2- x 3-cm abdominal wall defect was created in 80 rats. Rats were randomly assigned for repair with 2.5- x 3.5-cm PPM (n = 40) or 2.5- x 3.5-cm PPM plus polyglactin 910 mesh (PPM-PGM) (n = 40). The rats were sacrificed at 1, 2, 3, and 6 months (n = 10), and an autopsy was performed to determine herniation and adhesion rates. Mesh-fascia interface was taken for histology. RESULTS: In the PPM group, 1 rat died before the end of the experiment, and at 6 months one of the 10 rats had a herniation. In the PPM-PGM group, two rats died before the end of the experiment, and two rats had a herniation after 1 month and three rats after 6 months. At 1, 2, and 3 months the adhesion score in the PPM group (median, 3; range, 2-3) did not differ from the score in the PPM-PGM group (median, 3; range, 2-3). Also, at 6 months the adhesion score in the PPM group (median, 2; range, 2-3) did not differ from the score in the PPM-PGM group (median, 3; range, 2-3). At microscopy a capsule was formed around the PP fibers, which matured over months in the PPM group. In the first month after implantation an inflammatory response was seen. Histology was similar in both groups, although in the early PPM-PGM group the inflammatory response was more evident. CONCLUSION: Interposition of PGM between PPM and viscera does not alter adhesion formation nor influences herniation rate.

"Components separation technique" for the repair of large abdominal wall hernias.

BACKGROUND: The "components separation technique" is a method for abdominal wall reconstruction in patients with large midline hernias that cannot be closed primarily. The early and late results of this technique were evaluated in 43 patients. METHODS: Records of 43 patients, 11 women and 32 men, with a mean age of 49.7 (range 22 to 78), were reviewed for body length and weight, size and cause of the hernia, intra- and postoperative mortality and morbidity, with special attention given to wound and pulmonary complications. Patients were invited to attend the outpatient clinic afterward for at least 12 months for physical examination of the abdominal wall. RESULTS: The defect resulted after elective surgery in 19 patients and after acute surgery in 24 patients. In 11 patients, the defect was a result of open treatment of generalized peritonitis, and 13 patients had a recurrent incisional hernia. One patient died on the sixth postoperative day from mesenteric thrombosis. The postoperative course was complicated in 17 patients: fascial dehiscence in one, hematoma in five, seroma in two, wound infection in six, skin necrosis in one, and respiratory insufficiency in two. Thirty-eight patients were seen for followup. After a mean followup of 15.6 months (range 12 to 30 months), a recurrent hernia was found in 12 of the 38 patients (32%). The remaining four patients had no recurrent hernia after 1, 1, 3, and 4 months, respectively. CONCLUSIONS: The "components separation technique" is useful for the reconstruction of large abdominal wall hernias, especially under contaminated conditions in which the use of prosthetic material is contraindicated. Further research is needed to reduce the relatively high reherniation rate.