Risk factors for uterine dehiscence and rupture in case of vaginal birth after cesarean section.

INTRODUCTION: Vaginal delivery after caesarean section (VBAC) is recommended, but the rising rate of uterine rupture calls into question the safety of this practice. AIM: To identify risk factors for uterine dehiscence and rupture. METHODS: This was a prospective, analytical and descriptive observational study, carried out in a tertiary care maternity. We included all parturients with one previous caesarean section undergoing trial of labor. We assessed the quality of the uterine scar which was evaluated after delivery. RESULTS: We included 300 patients with one previous caesarean section undergoing trial of labor. The trial of labor was successful (vaginal delivery) in 50.7% of cases. The uterine scar, assessed after delivery, was of good quality in 79% of cases. We noted 7 cases of uterine rupture, i.e. 2.3% of cases, and dehiscence in 56 patients, i.e. 18.6% of cases. Parity, conditions of previous caesarean section (programmed or emergency) and interpregnancy interval were significantly related to the labor outcome (p=0.004, p=0.001 and p=0.135 respectively). The occurrence of rupture or dehiscence was not significantly related to macrosomia, defined as a neonatal weight greater than 4000g (p=0.135). CONCLUSION: Knowing the risk factors for uterine dehiscence and rupture would enable the obstetrician to properly assess the situation in order to make the correct decision and avoid neonatal and maternal complications.

Challenging frontiers in neuroplastic cranial reconstruction: addressing neurosurgical wound healing complications through interdisciplinary collaboration - an observational study.

BACKGROUND AND OBJECTIVES: Although rare, complications like skin dehiscence and necrosis after neurosurgery pose significant challenges by increasing the risk of infections spreading to the epidural, subdural, or intracerebral spaces. This retrospective, single-center study aims to assess the prior clinical courses, neuroplastic repair, and outcomes of  patients with skin defects following cranial neurosurgical procedures, and to outline our interdisciplinary reconstructive protocol. METHODS: A retrospective analysis was performed on cranial surgeries conducted at the Department of Neurosurgery,  spanning from 2017 to 2023. Patients with skin defects requiring the combined expertise of neurosurgery and plastic surgery for effective treatment were included. The sizes of the skin defects were measured using intraoperative photographs analyzed with the freeware ImageJ software, version 2018. All patients provided informed consent for the surgeries. If informed consent was not possible due to neurological deterioration, consent was sought from adult representatives or next of kin except for acute circumstances. All patients admitted to our hospital agree to the pseudonymized use of their medical data and tissue specimens for research purposes in their treatment contract. RESULTS: A cohort of 24 patients experiencing wound healing complications after neurosurgical procedures underwent a total of 29 interdisciplinary surgeries for the reconstruction of skin, dural, and bone defects.  After the neuroplastic surgery, 8 out of 24 patients (33.3%) developed surgical complications, with 6 of these requiring revision surgeries due to persistent cranial infection.  In all cases,  permanent wound closure was successfully achieved following adherence to the proposed treatment algorithm. CONCLUSIONS: Our study underscores the necessity of an integrated neurosurgical and plastic surgical approach to effectively manage wound healing complications in a single stage surgery. Key interventions include differentiation between necrosis and gaping lesions, alongside precise management of neurosurgical issues like cerebrospinal fluid fistulas and hydrocephalus. Plastic surgical expertise in assessing the possibilities and limitations of both local and free flap surgeries is essential.

Soft-Tissue Phenotype as a Risk Indicator of Peri-Implantitis and Peri-Implant Soft-Tissue Dehiscence-A Cross-Sectional Study.

AIM: To investigate the association, as well as to characterize the associated panel of pro- and anti-inflammatory markers, between the different components of the peri-implant phenotype and the presence of peri-implantitis/peri-implant soft-tissue dehiscence (PISTD). MATERIALS AND METHODS: A total of 324 implants in 112 patients were included. The following components of the peri-implant phenotype were clinically measured through the use of a manual periodontal probe or a digital calliper: keratinized mucosa width (PIKM-W), mucosal thickness (MT), attached mucosa (AM) and vestibulum depth (VD). The presence of peri-implantitis and PISTD was assessed through clinical and radiographic examination. Mixed-models logistic regression analyses were performed to analyse the association between peri-implant phenotype and the presence of peri-implantitis or PISTD, adjusting for relevant confounders. Multiplex immunoassays were employed to evaluate the peri-implant crevicular fluid levels of a panel of pro- and anti-inflammatory markers. RESULTS: Peri-implant health, peri-implant mucositis and peri-implantitis were diagnosed in 36.6%, 21.4% and 42% of the patients (classified according to their worst implant) and 35.2%, 34.3%, and 30.5% of the implants, respectively. In the multi-level multiple regression model, the absence of PIKM-W (odds ratio [OR] = 9.24; 95% CI: 2.73-31.28), the absence of attached mucosa (OR = 19.58; 95% CI: 6.12-62.56) and a reduced (<4 mm) vestibulum depth (OR = 2.61; 95% CI: 1.05-6.48) were associated with peri-implantitis. Similarly, the absence of PIKM-W (OR = 6.32; 95% CI: 1.67-23.83), a thin (<2 mm) mucosa (OR = 157.75; 95% CI: 14.06-1769.9) and a reduced vestibulum depth (OR = 3.32; 95% CI: 1.02-10.84) were associated with the presence of PISTD. Implants with PIKM-W = 0 mm showed statistically significantly higher levels of interferon-γ in both regular (≥2 maintenance/year) and irregular (<2 maintenance/year) compliers (p = 0.046 and p = 0.012). In irregular compliers, the absence of PIKM-W was also associated with statistically significantly higher levels of interleukin (IL)-1ß and IL-21 (p = 0.016, p = 0.046). These associations were independent of the effect of relevant confounders (e.g., plaque, compliance with maintenance, etc.). CONCLUSIONS: Within their limits, the present findings indicate that (a) peri-implant soft-tissue phenotype appears to be associated with the presence of peri-implantitis and PISTD, and (b) in the absence of PIKM-W, the inflammatory response seems to be dysregulated and the soft-tissue remodelling up-regulated.

Application and Prognostic Analysis of Vacuum Sealing Drainage in the Incision Infection in Patients With Stage II-III Colorectal Cancer.

INTRODUCTION: This study aims to explore the application value of vacuum sealing drainage (VSD) technology in the treatment of incision infection dehiscence after surgery in patients with stage II-III colorectal cancer and analyze its impact on prognosis. METHODS: This retrospective study included patients who experienced incision infection dehiscence after surgery for colorectal cancer between February 2014 and August 2019. Clinical and pathological data, short-term outcomes, and long-term outcomes were compared between the traditional group and the VSD group. RESULTS: A total of 97 patients were included in this study. There was no significant difference in clinical and pathological data between the traditional group and the VSD group (P > 0.05). The VSD group had fewer dressing changes, lower pain scores during dressing changes, and better granulation tissue growth grading than the traditional group, with statistical significance (P < 0.05). The VSD group started adjuvant chemotherapy earlier and had a higher proportion of ≥4 cycles of chemotherapy. The three-year overall survival rate in the VSD group was better than the traditional group, but the difference was not statistically significant (P > 0.05). CONCLUSION: The application of VSD technology can promote granulation tissue growth, accelerate incision healing, and facilitate patients to complete subsequent adjuvant chemotherapy. However, further verification of its long-term impact on prognosis requires longer-term follow-up results.

Abdominal wound closure in the presence of sepsis: our experience with the use of subcutaneous drain.

Objectives: Patients requiring surgery for secondary peritonitis demonstrate a significantly increased risk for incisional surgical site infection. This study aimed to evaluate the efficacy of subcutaneous wound drain post-laparotomy for contaminated surgical wounds. Design: This was a prospective comparative hospital-based study. Setting: Patients who had surgery for secondary peritonitis in Irrua Specialist Teaching Hospital were studied. Participants: Fifty patients aged 16 years and above who presented with secondary peritonitis. Intervention: Patients who met the inclusion criteria were randomized into two equal groups. Group A had a suction drain placed in the subcutaneous space after laparotomy while Group B did not. Main outcome measures: Development of incisional surgical site infection, wound dehiscence, and duration of post-operative hospital stay. Results: The incidence of incisional surgical site infection was significantly less in Group A (20%) than in Group B (68%). There was no case of wound dehiscence in Group A as against 3 (12%) in Group B. The difference was not statistically significant. The mean duration of hospital stay was significantly less with subcutaneous suction drain (8.96+2.81 Vs 14.04+8.05; p = 0.005). Conclusion: Subcutaneous suction drainage is beneficial in abdominal wall closure in cases of peritonitis as it significantly reduces the incidence of incisional surgical site infection and the duration of postoperative hospital stay. The reduction in surgical wound dehiscence observed in this study was, however, not statistically significant. Funding: None declared.

[Repair of Vaginal Cuff Dehiscence after Laparoscopic Radical Cystectomy with Gracilis Myocutaneous Flap].

Vaginal cuff dehiscence after total hysterectomy or total cystectomy had been increasing since laparoscopic or robotic surgery became a common surgery among gynecologists and urologists. A 52-yearold woman underwent laparoscopic radical total cystectomy for muscle invasive bladder carcinoma at Rakuwakai Otowa Hospital. She was emergently admitted with a fist-sized lump protruding from her vagina four months after surgery. Physical examination and her past history on admission disclosed vaginal cuff dehiscence after cystectomy. Computed tomographic scan and magnetic resonance imaging showed no bowel evisceration in the lump. We confirmed that the content of lump was peritoneal tissue and removed it by laparoscopic surgery. Simultaneously, we repaired the vaginal cuff dehiscence with a gracilis myocutaneous flap. There was no subsequent recurrence of vaginal dehiscence or bladder carcinoma in one-year follow-up.

Ipsilateral dual cannulation is associated with wound complications following veno-arterial ECMO decannulation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is a well-established treatment for severe cardio-pulmonary failure. The use of large bore cannulas in the femoral vessels for an extended period has been associated with significant wound complications. There is a lack of data analyzing risk factors that can mitigate such complications. The primary purpose of this study was to identify modifiable risk factors associated with femoral wound complications after VA ECMO decannulation. METHODS: Retrospective analysis of wound complications in patients following VA ECMO decannulation from 2014-2021 at a single academic institution were analyzed. Wound complications were defined as wound infection, dehiscence, or those wounds that were deliberately opened to promote healing by secondary intention. RESULTS: Sixty patients underwent decannulation of VA ECMO with operative repair of the femoral artery. Fifteen patients were identified to have wound complications, eight (53%) of these had infection. Fourteen (93%) patients had wound dehiscence or had their wound purposely opened at bedside. Univariate analysis revealed no association of access-related complication with higher Body Mass Index (BMI, 28.3 vs. 32.7 kg/m2, P=0.110) but here was a trend in having more wound complications in individuals with COVID-19 infection (6.7% vs. 26.7%, P=0.058). Patients that had dual cannulation with the arterial and venous cannulas in the same groin had significantly more wound complications compared to single cannulation arterial and venous cannulas in separate groins (57.8% vs. 93.3%; P=0.012). Multivariate analysis revealed same side cannulation (OR 18.05, 95% CI 1.44-226.18, P=0.025) and COVID-19 infection (OR 18.18, 95% CI 1.50-220.66, P=0.023) were independent predictors of wound complications. CONCLUSIONS: Wound complications after VA ECMO decannulation is associated with COVID-19 infection and having venous and arterial cannulas in the same groin. We recommend that the arterial and venous cannulation be placed in different groins in patients that require VA ECMO.

Risk factors and incidence of short-term complications following open reduction and internal fixation of scapula fractures.

PURPOSE: To determine the short-term complication rates following open reduction and internal fixation of scapula fractures, factors affecting the development of adverse events, and complication rates based on the anatomic location of the fracture. METHODS: Thirty-day complication rates for patients who underwent open reduction and internal fixation of the scapula were compared between glenoid, body, coracoid, and acromion fracture locations, as identified by International Classification of Disease codes. Possible adverse events included postoperative surgical site infection, renal insufficiency, intubation, pneumonia, deep vein thrombosis, pulmonary embolism, urinary tract infection, wound dehiscence, stroke, and blood transfusion. RESULTS: A total of 251 scapula fractures were identified, with 161 having known fracture locations: 105 glenoid, 20 body, 9 coracoid, and 27 acromial fractures. The rate of any adverse event for all scapular fractures was 2.0%, with no significant difference between anatomic locations (p = 0.79). The overall rates of transfusion, surgical site infection, and return to OR were 0.4%, 0.8%, and 3.98%. Steroid use associated with a significantly increased risk of any adverse event (OR: 55.57, p = 0.038) and outpatient status demonstrated a protective effect on reoperation (OR: 0.11, p = 0.014). There were no significant differences in the rates between groups [transfusion (p = 0.91); surgical site infection (p = 0.17); reoperation (p = 0.85)]. CONCLUSION: Complication rates within thirty days of ORIF for scapula fracture were low. Reoperation was the most common complication, followed by surgical site infection, wound dehiscence, stroke, transfusion, and pneumonia. Steroid use was a risk factor for developing any adverse event, and outpatient status was protective against reoperation. The 30-day complication profile of glenoid, body, coracoid, and acromial fractures was not significantly different. The low complication rates support the relative short-term safety of operative intervention with internal fixation. LEVEL OF EVIDENCE: Level III.

Effect of Chronic Steroid Use on Postoperative Wound Complications in Patients Undergoing Arterial Bypass Surgery for Lower Extremity Peripheral Arterial Disease.

BACKGROUND: While existing literature reports adverse effects of chronic steroid use on surgical wound outcomes, there remains lack of data exploring the effect of steroids on postoperative outcomes following lower extremity arterial bypass surgery. This study aims to explore the effect of chronic steroid use on surgical outcomes in patients undergoing open revascularization for lower extremity arterial occlusive disease. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2020, all patients receiving aortoiliac or infrainguinal arterial bypass for peripheral arterial disease (PAD) were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and 30-day outcomes were compared using χ2 test and independent t-test, and the association of chronic steroid use with wound complications was studied using multivariable logistic regression analysis. RESULTS: A total of 44,675 patients undergoing open lower extremity revascularization (LER) were identified, of which 1,807 patients were on chronic steroids, and 42,868 patients were not on chronic steroids. On multivariable logistic regression analysis, being on chronic steroids was associated with higher rates of deep surgical site infections (SSIs) (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.03-1.83), any SSI (OR 1.22, 95% CI 1.04-1.43), and wound dehiscence (OR 1.42, 95% CI 1.03-1.96). Chronic steroid users also had significantly increased odds of developing sepsis (OR 1.56, 95% CI 1.19-2.04), pneumonia (OR 1.44, 95% CI 1.08-1.91), urinary tract infection (UTI) (OR 1.54, 95% CI 11.13-2.09), deep vein thrombosis (DVT) (OR 1.60, 95% CI 1.01-2.53), 30-day readmission (OR 1.30, 95% CI 1.12-1.50), reoperation (OR 1.17, 95% CI 1.01-1.37), and mortality (OR 1.33, 95% CI 1.01-1.76) compared with nonchronic steroid users. CONCLUSIONS: This study confirms that chronic corticosteroid use is associated with higher risk of SSIs in patients undergoing lower extremity arterial bypass surgery. These patients typically have various underlying health issues, emphasizing the need for personalized treatment and management to reduce steroid-related postoperative complications and improve survival.

Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset.

Transvaginal organ prolapse, such as small bowel evisceration, is a rare complication after radical cystectomy (RC) in female patients with invasive bladder cancer, However, it often requires emergency surgical repair. Here, we describe our experience with such a case and a review of similar previously reported cases, along with evaluation of the risk factors. We also propose a vaginal reconstruction technique to prevent this complication during robot-assisted laparoscopic radical cystectomy (RARC). A total of 178 patients who underwent laparoscopic radical cystectomy (LRC) or RARC were enrolled, 34 of whom (19%) were female. One of the 34 female patients had transvaginal small bowel evisceration after RARC. We evaluated our case and six such previously reported cases, to determine vaginal reconstruction techniques during RARC to prevent this complication postoperatively. Median age of these cases was 73 (51-80) years, and all patients were postmenopausal. The median time to small bowel evisceration was 14 (6-120) weeks postoperatively. In addition, we changed the methods of the vaginal reconstruction technique during RARC from the conventional side-to-side closure technique to the improved caudal-to-cephalad closure technique. Since implementing this change, we have not experienced any cases of vaginal vault dehiscence or organ prolapse. Transvaginal small bowel evisceration after RC can easily become severe. Therefore, all possible preventive measures should be taken during RARC. We believe that our vaginal reconstruction techniques might reduce the risk of developing this complication.

Assessment of risk factors for postoperative complications of breast reduction by superior or superomedial pedicle.

BACKGROUND: Some risk factors for breast reduction complications are well known but for others the results are contradictory in scientific literature. The choice between superior pedicle and superomedial pedicle as a risk factor has been rarely studied. We aim to better identify the risk factors for breast reduction complications, including the choice between these two pedicles, in order to better prevent their occurrence. METHODS: We performed a retrospective analysis of the medical records of patients who underwent a bilateral breast reduction from august 2020 to august 2023 in our center. Patient data were obtained and correlated with postoperative complications using statistical tests and a literature search was carried out to compare our results to the current evidence. RESULTS: We included 216 patients. The complication rate was 24.07%. The most frequent complication was wound dehiscence (17.59%), followed by partial Nipple-Areola-Complex necrosis or peroperative suffering requiring conversion to Nipple-Areola-Complex free graft (5.56%). Increased Body Mass Index, superomedial pedicle and resection weight ≥650g were associated with an increased probability of complication occurrence (P=0.048, P=0.005 and P=0.044). The superomedial pedicle and the resection weight ≥650g were associated with an increased probability of wound dehiscence (P=0.005 and P=0.037). The difference between the preoperative and the postoperative Sternal-Notch-Nipple distance was associated with an increased probability of partial Nipple-Areola-Complex necrosis or Nipple-Areola-Complex free graft (P=0.014). CONCLUSION: Correcting modifiable preoperative risk factors and mastering both techniques, enabling the surgeon to choose the one best suited to each patient's clinical situation, reduces the complication rate.

Effects of subcutaneous drain on wound dehiscence and infection in gynecological midline laparotomy: Secondary analysis of a Korean Gynecologic Oncology Group study (KGOG 4001).

OBJECTIVE: To identify the effects of subcutaneous drain insertion on wound dehiscence and infection in patients who underwent gynecological midline laparotomy. METHODS: This analysis identified the secondary endpoints of the KGOG 4001 study, a prospective, multicenter, non-blind, randomized controlled trial. Patients scheduled to undergo midline laparotomy for gynecological diseases and, with body mass index<35 kg/m2, were randomized (1:1) to treatment (with subcutaneous drain) and control (without subcutaneous drain) groups from February 2021 to December 2021. We compared the incidence rate of wound dehiscence 4 weeks post-surgery and the cumulative incidence rate of wound dehiscence and infection up to 4 weeks post-surgery between the two groups. RESULTS: Of 174 patients randomized to the treatment (n = 84) and control (n = 90) groups, 12 were excluded owing to loss to follow-up; finally, 162 patients (treatment, n = 79; control, n = 83) were included in intention-to-treat analysis. The frequency of cancer surgery (79.7 % vs. 77.1 %, p = 0.683), mean surgery time (227.7 vs. 226.7 min, p = 0.960), and mean wound length (24.2 vs. 24.3 cm, p = 0.933) were comparable between two groups. No significant differences were observed in the incidence rate of wound dehiscence 4 weeks post-surgery (1.3 % vs. 2.4 %, p > 0.999), cumulative incidence rate of wound dehiscence (8.9 % vs. 6.0 %, p = 0.491), and cumulative incidence rate of wound infection (1.3 % vs. 0.0 %, p = 0.488) up to 4 weeks post-surgery between the two groups. CONCLUSION: Subcutaneous drain insertion is not associated with a significant improvement in the incidence of wound dehiscence and infection in patients who undergo gynecological midline laparotomy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04643197.

Severe Complications of Uterine Dehiscence Post-Lower Segment Cesarean Section: A Case Report Emphasizing the Importance of Timely Diagnosis and Intervention.

BACKGROUND Uterine dehiscence, an infrequent event often mistaken for uterine rupture, is rarely linked to post-cesarean section procedures and can result in severe complications, notably puerperal sepsis. In this report, we present a case that exemplifies the onset of puerperal sepsis and the emergence of intra-abdominal abscesses attributed to uterine dehiscence following a lower segment cesarean section (LSCS). CASE REPORT Our patient, a 28-year-old woman in her third pregnancy, underwent LSCS 1 week earlier. Subsequently, she returned to the hospital with lower abdominal pains, fever, and malodorous vaginal discharge. Computed tomography (CT) scan of whole abdomen verified uterine dehiscence and pus collection at the subhepatic region and right paracolic gutter. After referral to a specialized hospital, laboratory findings indicated an elevated white blood cell count and alkaline phosphatase levels, and coagulation abnormalities. She underwent an exploratory laparotomy, which unveiled uterine dehiscence, abscesses, and adhesions, necessitating a total abdominal hysterectomy and abdominal toileting. Pus culture analysis identified the presence of E. coli, which was susceptible to ampicillin/sulbactam. Complications were encountered after surgery, including wound dehiscence and pus re-accumulation. Successful management involved vacuum dressings and percutaneous drainage. Eventually, her condition improved and she was discharged, without additional complications. CONCLUSIONS This report underscores the importance of considering cesarean scar dehiscence as a diagnosis in women with previous cesarean deliveries who present during subsequent pregnancies with symptoms such as abdominal pain or abdominal sepsis. Diagnostic tools, such as CT, play pivotal roles, and the timely performance of an exploratory laparotomy is paramount when suspicion arises.

Does the adjunctive use of autologous platelet concentrate during secondary alveolar bone grafting reduce the risk of wound dehiscence? A systematic review and meta-analysis.

Wound dehiscence is a common complication after secondary alveolar bone grafting (SABG), leading to unfavourable surgical outcomes. Studies have shown that autologous platelet concentrates (APC) may enhance wound healing and improve outcomes. Therefore, this review aimed to evaluate in patients with alveolar clefts, whether using APC and iliac crest bone graft can mitigate the likelihood of wound dehiscence formation compared with those who underwent iliac bone grafting only following SABG. A comprehensive literature search was conducted using various electronic databases, including PubMed, Embase, Scopus, Web of Science, EBSCOhost, Ovid MEDLINE, LILACS, Cochrane Library, and grey literature, to include studies until July 31, 2023, without any restriction to language and time of publication. Only randomized (RCT) and controlled (CCT) clinical trials were included. Two independent reviewers screened the studies based on the predefined criteria, after which a qualitative and quantitative analysis was conducted. The search yielded 821 studies, of which seven were deemed eligible for systematic review. The risk of bias assessment done using "The Cochrane collaboration tool for risk of bias assessment" for six RCTs and the "Risk of Bias in Non-randomized Studies - of Interventions" for one CCT revealed a moderate to high risk of bias. The meta-analysis of five studies showed that the overall risk of developing wound dehiscence was lower in the APC group (RR = 0.33; 95% CI: 0.16, 0.71; p = 0.005; χ2 = 0.82; I2 = 0%). Subgroup analyses based on study design further supported these findings. Although the adjuvant use of APC for alveolar cleft reconstruction reduces the risk of wound dehiscence, more studies with increased scientific rigour and fewer confounding variables are warranted.

Dehiscence and Fistula Formation Following Anterior Palatal Reconstruction With Vomer Flap.

BACKGROUND AND PURPOSE: Anterior palatal reconstruction using vomer flaps has been described during primary cleft lip repair. In this procedure, the mucoperiosteal tissue of the vomer is elevated to reconstruct the nasal mucosa overlying the cleft of the hard palate. Here the authors, evaluate the efficacy of a technique in which a superiorly based vomer flap is sutured to the lateral nasal mucosa. The authors assess vomer flap dehiscence rates and compare the likelihood of fistula development in this cohort to patients who underwent palatoplasty without vomer flap reconstruction. METHODS: A retrospective chart review was conducted of all palatoplasties performed by the senior author at an academic institution during a 7-year period. Medical records were reviewed for demographic variables, operative characteristics, and postoperative complications up to 1 year following surgery. Logistic regression analysis was conducted to assess the effects of vomer flap reconstruction on fistula formation, adjusting for age and sex. RESULTS: Fifty-eight (N=58) patients met the inclusion criteria. Of these, 38 patients (control group) underwent cleft palate reconstruction without previous vomer flap placement. The remaining 20 patients underwent cleft lip repair with vomer flap reconstruction before palatoplasty (vomer flap group). When bilateral cases were counted independently, 25 total vomer flap reconstructions were performed. Seventeen of these 25 vomer flap reconstructions (68%) were completely dehisced by the time of cleft palate repair. In the vomer flap group, 3 of the 20 patients (15%) developed fistulas in the anterior hard palate following the subsequent palatoplasty procedure. In the control group, only 1 of the 38 patients (2.6%) developed a fistula in the anterior hard palate. There was no significant association between cohorts and the development of anterior hard palate fistulas [odds ratio=10.88, 95% confidence interval (0.99-297.77) P =0.07], although analysis was limited by low statistical power due to the small sample size. CONCLUSIONS: In our patient population, anterior palatal reconstruction using a superiorly based vomer flap technique was associated with complete dehiscence in 68% of cases. Fistula formation in the anterior hard palate was also proportionately higher following initial vomer flap reconstruction (15% versus 2.6%). These results prompted the senior author to adjust his surgical technique to 1 in which the vomer flap overlaps the oral mucosa. While follow-up from these adjusted vomer flap reconstruction cases remains ongoing, early evidence suggests a reduced requirement for surgical revision following implementation of the modified technique.

Open intraperitoneal onlay mesh repair with anterior component separation as a bail-out procedure in the management of complex hernias.

PURPOSE: Surgical repair of complex abdominal wall hernias remains technically demanding and is widely recognized as a risk factor for unfavorable outcomes with high recurrence and morbidity rates. The objective is to assess short- and long-term complications after open intraperitoneal onlay mesh (IPOM) repair combined with bilateral anterior component separation (ACS) for large and difficult incisional hernias, alongside evaluating hernia recurrence rates. METHODS: This retrospective analysis utilized data sourced from Hospital electronic health records and a prospective database at an academic tertiary referral center. Data collection was carried out from patients operated between January 2006 and December 2017. Eligible patients had complex incisional hernias measuring at least 10 cm in their transverse diameter and had an open IPOM repair with bilateral ACS. RESULTS: In our study group of 45 patients, the 30-day surgical site occurrence (SSO) rate was high (37.8%), primarily consisting of superficial postoperative complications as seroma (17.8%) and wound dehiscence (6.7%). Among six patients (13.3%), wound complications escalated to chronic infected mesh-related problems, leading to complete mesh removal in four cases (8.9%) and partial mesh removal in two cases (4.4%). Regarding long-term complications, five patients (11.1%) developed enterocutaneous fistula. The recurrence rate was modest [5 out of 41 (12.2%)] over a median follow-up period of 99 months. CONCLUSIONS: Despite a high SSO rate, application of the open IPOM technique with ACS could serve as a valuable rescue option for managing large and complex hernias, with acceptable hernia recurrence rates at long-term follow-up.

Prophylactic Transversely Hemisected Sartorius Flap for High-Risk Groin Dissections in Vascular Surgery-A Case Series.

Groin wound dehiscence and infection are a common complication of femoral artery exposure. In patients with prosthetic conduits placed in the groin, these complications can lead to graft infection or anastomotic dehiscence with hemorrhage. Sartorius flaps can be useful in preventing graft infections or anastomotic breakdown in the setting of wound infections. Prophylactic sartorius flaps have been suggested to be a useful adjunct in patients who are at high risk for groin complications. Standard sartorius flaps can be difficult to perform and increase the operative time. We present our experience with a modified sartorius flap, a Transversely Hemisected Sartorius (THT), which avoids dissection to the anterior superior iliac spine. Patients who received femoral artery exposure and a modified prophylactic sartorius flap were included in this case series. The Penn Groin Assessment Scale (PGAS) was calculated for each patient and our primary outcome was the rate of deep space wound infections. Fifteen patients received a THT muscle flap. The average age of the cohort was 67.5 (35-86) years. Eight (50%) were male. The mean PGAS was 2.5 (0-6). Eight (50%) groins had a prosthetic conduit underlying the flap. Four (25%) patients had infrainguinal bypass, 3 (18.8%) for femoral-femoral bypass, and 1 (6.3%) patient received aortic-bifemoral bypass. Eight (50%) patients received sartorius flap after femoral artery exposure for thromboembolectomy, endarterectomy, or access complications. Six (37.5%) patients developed superficial surgical site infections however no deep space infections or prosthetic graft excisions resulted. This procedure was effective in preventing graft infections in all patients with high-risk features for groin infection in our retrospective case series. The segmental blood supply is maintained while providing good coverage of the femoral vessels with this rotational flap.

Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy.

INTRODUCTION: Emergent laparotomy is associated with significant wound complications including surgical site infections (SSIs) and fascial dehiscence. Triclosan-coated barbed (TCB) suture for fascial closure has been shown to reduce local complications but primarily in elective settings. We sought to evaluate the effect of TCB emergency laparotomy fascial closure on major wound complications. METHODS: Adult patients undergoing emergency laparotomy were prospectively evaluated over 1 year. Patients were grouped into TCB versus polydioxanone (PDS) for fascial closure. Subanalysis was performed on patients undergoing single-stage laparotomy. Primary outcomes were SSI and fascial dehiscence. Multivariate analysis identified independent factors associated with SSI and fascial dehiscence. RESULTS: Of the 206 laparotomies, 73 (35%) were closed with TCB, and 133 (65%) were closed with PDS. Trauma was the reason for laparotomy in 73% of cases; damage-control laparotomy was performed in 27% of cases. The overall rate of SSI and fascial dehiscence was 18% and 10%, respectively. Operative strategy was similar between groups, including damage-control laparotomy, wound vac use, skin closure, and blood products. Surgical site infection events trended lower with TCB versus PDS closure (11% vs. 21%, p = 0.07), and fascial dehiscence was significantly lower with TCB versus PDS (4% vs. 14%, p < 0.05). Subanalysis of trauma and nontrauma cases showed no difference in SSI or fascial dehiscence. Multivariable analysis found that TCB decreased the likelihood of fascial dehiscence (odds ratio, 0.07; p < 0.05) following emergency laparotomy. Increased odds of fascial dehiscence were seen in damage-control laparotomy (odds ratio, 3.1; p < 0.05). CONCLUSION: Emergency laparotomy fascial closure with TCB showed significantly decreased rates of fascial dehiscence compared with closure with PDS and a strong trend toward lower SSI events. Triclosan-coated barbed suture was independently associated with decreased fascial dehiscence rates after emergency laparotomy. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.