Clinical Application of the Measurement of Abdominal Wall Tension in Hernia Repair.

Abdominal wall tension is an integral concept in hernia repair. Most of the described techniques attempt to reduce abdominal wall tension by using mesh prosthetics or myofascial release. Although the concept of a "tension-free" hernia repair is well-understood and appreciated by surgeons, quantitative information about abdominal wall tension is limited. This review evaluates the published literature related to abdominal wall tension and summarizes how the measurement of intraoperative tension can guide clinical decision-making. Most of the methods and techniques for measuring abdominal wall tension are similar and involve the use of tensiometers. However, there is no accepted standardized technique. Baseline tension measurements confirm the concept of a baseline physiological tension, and it has been observed that tension does not correlate with hernia width. When the tension is considered to be too great during hernia repair, intraoperative techniques such as myofascial release can be used to reduce tension to physiological values. Emerging data from clinical studies on tension have added to our understanding of the mechanics and physiology of the abdominal wall. Standardized devices and measurement techniques need to be developed and validated to foster the utility of tension measurements in hernia repair.

Assessing resident performance and training of colonoscopy in a general surgery training program.

BACKGROUND: Recently, the adequacy of endoscopy training in general surgery residency programs has been questioned. Efforts to improve resident endoscopic training and to judge competency are ongoing but not well studied. We assessed resident performance using two assessment tools in colonoscopy in a general surgery residency program. METHODS: Prospectively collected data were reviewed from consecutive colonoscopies by a single surgeon: September 2008 to June 2011. Colonoscopies performed without residents were excluded. Data included patient demographics, procedural data, and outcomes. Following the colonoscopy, residents were graded by the attending surgeon using up two different assessment tools. Descriptive statistics were calculated and outcomes were compared. RESULTS: Colonoscopies were performed by residents in 100 patients. Average age was 52 (range, 22-79) years. Females made up 66 % of patients, and 63 % were Caucasian. Postgraduate level (PG-Y) 3 level residents performed 72 % of colonoscopies. The average resident participation was 73 % of the procedure. Biopsies were performed in 35 %; adenomatous polyps were found in 17 % and invasive cancer in 1 %. Bowel preparation was deemed good in 76 % of patients. Colonoscopy was completed in 90 % of patients. Reasons for incomplete exam were technical (7 patients), inability to pass a stricture (2 patients), and poor prep (1 patient). For completed full colonoscopies, the average time to reach the cecum was 22 min, and withdrawal time was 13 min. Resident assessments were made in 89 of the colonoscopies using 2 separate assessment tools. There were no mortalities; the morbidity rate was 3 %. Morbidities included a perforation related to a biopsy requiring surgery and partial colectomy, a postpolypectomy bleed requiring repeat colonoscopy with clipping of the bleeding vessel, and a patient with transient bradycardia requiring atropine during the procedure. CONCLUSIONS: Using objective assessment tools, overall resident skill and knowledge in performing colonoscopy appears to improve based on increasing PG-Y level, although this was not evident with all categories measured. Methods to assess competency continue to evolve and should be the focus of future research.

Educating Residents in Abdominal Wall Closure: An Overview.

Background and Aims: Incisional hernia prevention has become an important concept for surgeons operating on the abdominal wall. Several techniques have been proposed to help decrease incisional hernia formation with suture closure of the abdominal wall being one of the cornerstones. Technical details that have been reported to decrease incisional hernia rates include achieving a 4:1 Suture to Wound length ratio and the use of a small bites technique. Despite evidence to support many of these techniques there appears to be a gap in practice patterns amongst practicing surgeons. Introducing and promoting these principles in surgical residency may help to close this gap. This paper reviews our experience with surgical training for abdominal wall closures at our institution. Materials and Methods: Programs and projects related to abdominal wall closure were reviewed from our institution from 2010-Present. Type of project, intervention, and impact on education was evaluated and summarized. Results: Seven projects were identified relating to surgical training and abdominal wall closure. Three projects dealt with skills training using an abdominal wall simulation model and related to suturing techniques. Two projects were clinical studies focused on suture to wound length ratios and improving outcomes with this variable in a residency training program. Two projects dealt with models relating to abdominal wall closure and education. Conclusion: Implementation of educational programs in surgical residency programs can lead to improvements in technique and knowledge around abdominal wall closure and help in research endeavors.

An Evaluation of Fascial Closure Techniques in Open Ventral Hernia Repair: Practice Patterns and Short-Term Outcomes.

The best method for fascial closure during hernia repair remains unknown. This study evaluates the impact of fascial closure techniques on short-term outcomes. All patients undergoing open ventral hernia repair were queried using the Americas Hernia Society Quality Collaborative database. Analysis was stratified by suture type (absorbable and permanent) and technique (figure-of-eight, running, and interrupted). Outcome measures included SSI, surgical site occurrence (SSO), SSO requiring intervention, recurrence rate, and quality of life. Descriptive statistics and logistic regression were used. The study included 6544 patients. Two-thirds of surgeons closed fascia during ventral hernia repair with absorbable suture and one-third with permanent suture. In the absorbable group, 17 per cent used figure-of-eight, 46 per cent running, and 4 per cent interrupted suture. In the permanent group, 13 per cent used figure-of-eight, 8 per cent running, and 11 per cent interrupted suture. There was no significant association between SSO and closure technique (P = 0.2). However, SSO and suture type were significant (P < 0.001) with the odds of SSO for closure with absorbable suture being 62 per cent higher than the odds of permanent. Fascial closure technique and suture type had no significant association (P > 0.5) with SSI, SSO requiring intervention, hernia recurrence rate, or HerQLes or NIH PROMIS 3a scores at 30 days or 6 months. Fascial closure technique and suture material do not have a major impact on outcomes in ventral hernia repair. Despite a significantly higher rate of SSO for absorbable sutures than permanent, this did not increase the rate of interventions.

Rationale and Technique for Measuring Abdominal Wall Tension in Hernia Repair.

We describe a method to measure abdominal wall tension during hernia surgery and evaluate a possible correlation between hernia defect width and abdominal wall tension. After Institutional Review Board approval and informed consent, a prospective trial to measure intraabdominal tension was undertaken (May 2013 through March 2017). Tension measurements were obtained using tensiometers. Total tension, hernia defect width, and surgeon's estimation of tension were recorded. Correlation between defect width and total abdominal wall tension was assessed using multivariate analysis and a multiple linear regression analysis. An r-squared value > 0.6 was considered significant. Fifty-nine patients underwent hernia repair with concomitant tension measurements obtained at surgery. The average patient age was 61 years (range 29-81 years), 85 per cent were white, and 56 per cent female. The average total tension was 6.7 pounds (range 0.2-22 pounds) and average defect width was 8.6 cm (range 2-25 cm). The surgeon rated the fascia to be excellent in 15 per cent, good in 58 per cent, and fair in 27 per cent. The average estimation of tension by the surgeon was 5 pounds (range 2-10 pounds). We found no correlation between hernia defect size and total abdominal wall tension and no correlation between the surgeon-estimated tension and objectively measured tension. We found no correlation between the width of the hernia defect and tension associated with approximating the midline. Further study regarding the practicality and usefulness of abdominal wall tension measurements during hernia surgery is needed.

The first fluorescent diboronic acid sensor specific for hepatocellular carcinoma cells expressing sialyl Lewis X.

Carbohydrate antigens with subterminal fucosylation have been implicated in the development and progression of several cancers, including hepatocellular carcinoma (HCC). Fluorescent sensors targeting fucosylated carbohydrate antigens could potentially be used for diagnostic and other applications. We have designed and synthesized a series of 26 diboronic acid compounds as potential fluorescent sensors for such carbohydrates. Among these compounds, 7q was able to fluorescently label cells expressing high levels of sLex (HEPG2) within a concentration range of 0.5 to 10 microM. This compound (7q) did not label cells expressing Lewis Y (HEP3B), nor cells without fucosylated antigens (COS7). This represents the first example of a fluorescent compound labeling cells based on cell surface carbohydrate structures.

The effect of watchful waiting on the management and treatment of inguinal hernias in a community setting.

A landmark study by Fitzgibbons et al. reported the safety of watchful waiting in men with minimally symptomatic inguinal hernias. The extent to which this study has changed practice patterns is unknown. The purpose of our study was to survey physicians caring for patients with hernia in our community to determine if the Fitzgibbons report impacted their medical practices. We sent an electronic survey containing questions regarding physician background and familiarity with the 2006 New England Journal of Medicine report on watchful waiting to physicians in our community. The online survey was accessed by 77 physicians; 74 completed the survey. Of 74 participants, surgeons accounted for 15 per cent, family/internal medicine 42 per cent, and 13 other specialties 43 per cent. Nonsurgeons were less familiar with the Fitzgibbons report. All surgeons had heard of the study, and 73 per cent had read it compared with 3 per cent of nonsurgeons. In nonsurgeon physicians, 38 per cent preferred letting patients with inguinal hernia decide treatment after counseling, 30 per cent sent all patients to a surgeon, and 25 per cent sent only symptomatic patients to a surgeon. Surgeons let patients decide after counseling in 73 per cent and chose watchful waiting for asymptomatic patients/offered surgery to symptomatic patients in 27 per cent. Based on our survey, Fitzgibbons' watchful waiting report does not appear to have significantly impacted practice and referral patterns in our community, although the watchful waiting strategy outlined in the study is practiced. Our study illustrates the challenge of translating research outcomes into clinical practice. Further research on ways to disseminate important surgical information to nonsurgeons seems warranted.

The effect of temporal artery biopsy on the treatment of temporal arteritis.

BACKGROUND: Temporal artery biopsy (TAB) is frequently used to guide treatment for suspected temporal arteritis. Our purpose was to determine the influence on subsequent temporal arteritis treatment, particularly the initiation, termination, or continuation of corticosteroids after a histologically negative TAB. METHODS: This is a retrospective analysis from a single regional referral center on all patients undergoing TAB March 2003 through November 2010. Demographic, clinical, and surgical informations were recorded including changes in treatment based on biopsy results. RESULTS: In all, 237 patients had complete documentation for review; the average age was 71 years (range 34 to 94) and 56% were women. Thirty-six patients had 42 positive biopsies; 26 biopsies were bilateral. Positive biopsy results were defined as having marked intimal thickening, transmural inflammation, and "giant cells." Neither length of biopsy specimen nor preoperative steroid use affected pathologic diagnosis (2.41 vs 2.38 cm, P = .46, and 52% vs 50%, P = .8, respectively). Symptoms included new-onset headache (75%), preauricular tenderness and jaw claudication (32%), erythrocyte sedimentation rate greater than 50 mm/h (60%), and a score of 3 or more using the American College of Rheumatology criteria (56%). Among the 56% of patients who met the criteria for the clinical diagnosis of temporal arteritis, 22% demonstrated a positive biopsy. Biopsy results had no significant impact on subsequent treatment in 69% of patients who met clinical diagnostic criteria (P = .7); in the remaining 31%, biopsy results altered subsequent treatment with either corticosteroid initiation or discontinuation. CONCLUSIONS: The pathologic results of the TAB did not significantly affect treatment in most patients.

Atypical hernias: suprapubic, subxiphoid, and flank.

Thorough knowledge of anatomy, appropriate preoperative planning, and reliance on the principles of hernia repair ensure successful outcomes. There are many options for repair, including technique and mesh choice. The hernia surgeon should be well versed in the open and laparoscopic approaches and apply them based on the individual clinical presentation. Long-term outcomes related to suprapubic, subxiphoid, and lateral hernia repairs are limited; however, open and laparoscopic repairs using wide mesh overlap and adequate fixation have acceptable outcomes and recurrence rates. Future research will likely focus on comparative studies based on patient factors, techniques, mesh, and cost.

Assessing Competency and Training of Upper Endoscopy in a General Surgery Residency Program.

BACKGROUND: Guidelines for optimal endoscopic training for surgical residents have not been formally integrated into modern teaching programs. Our purpose was to apply two endoscopic evaluation tools (EE-1 and EE-2) designed to measure surgical resident competency in the performance of esophagogastroduodenoscopy (EGD). METHODS: Prospectively collected data were reviewed from consecutive EGDs in a single institution by a single attending surgeon over 3 years (July 2008 to July 2011). Demographic, procedural, and outcome data were collected. Residents were graded at the completion of each procedure by the attending surgeon using EE-1 and EE-2. Descriptive statistics were calculated, and comparisons based on PGY levels were made using Fisher's exact and Kruskal-Wallis tests. P < 0.05 was considered significant. RESULTS: All procedures (N = 50) were performed by residents under the direct attending surgeon supervision. Average patient age was 51 years (range, 31-79 years), 66% were women, and 66% were Caucasian. PGY-3 residents performed 62% of the procedures. Average resident participation was 84% of each procedure. Biopsies were performed in 80% of patients and dilatations in 16%. All EGDs were successfully completed (average time, 13.1 min). EE-1 results demonstrated significantly different grades (P < 0.05) among PGY levels in seven of eight variables. EE-2 grades were significantly different (P < 0.05) among PGY levels in all 10 variables with a general trend of improvement as PGY level increased. There were no mortalities or morbidities. CONCLUSIONS: Residents can perform EGDs safely and expeditiously with appropriate supervision. Methods to assess competency continue to evolve and should remain an area of active research.

Teaching cholangiography in a surgical residency program.

OBJECTIVE: To evaluate the time associated with routine cholangiography in a residency teaching program. DESIGN: We retrospectively reviewed all patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography by a single surgeon from April 2010 to September 2011. Cholangiogram time, demographic, and operative information was recorded, and factors associated with increased cholangiogram times were compared using Fisher's exact test, Kruskal-Wallis test, and linear regression; a p value <0.05 was considered significant. SETTING: Academic-affiliated community-based surgical residency program. PARTICIPANTS: 10 surgical residents, PGY 1-5. RESULTS: Laparoscopic cholecystectomy with intraoperative cholangiography was performed in 54 patients. The average patient age was 43 years; 69% were Caucasian and 74% were female. Cholangiography was successful in 96% of patients. The average time for cholangiograms performed by residents was 11 minutes (range, 6-22 minutes) and average operating room time was 68 minutes (range, 32-103 minutes). The average percentage of case time for cholangiography was 17% (range, 9%-63%). Minor technical complications related to cholangiograms occurred in 33% of cases, with the most common being difficulty with clipping the catheter (20%). There was no significant difference in completion rate or cholangiogram time based on resident level of experience (p > 0.05). CONCLUSIONS: Intraoperative cholangiogram can be safely performed by residents at every level during laparoscopic cholecystectomy without adding significant time to the operation.

Use and indications of human acellular dermis in ventral hernia repair at a community hospital.

Background. To evaluate the use, indications, and short-term outcomes for human acellular dermis. Methods. We retrospectively reviewed patients having human acellular dermis placed for ventral hernia repair from January 2008 through October 2009. Demographic information, operative details, and outcomes of patients with and without recurrences were compared; a P value <0.05 was considered significant. Results. 115 patients met inclusion criteria. The average age was 60 years (range, 24-89). The technique of repair included primary repair with overlay of mesh in 76%, bridge repair in 13%, and underlay in 11%. Average cost of mesh per operation was $3,709 (range $191-10,630). Open repairs were performed in 90% of patients with addition of component separation in 12%. At an average of 13 months, 58 patients were available for followup (50%), with a 47% recurrence rate. The morbidity rate was 48% and the mortality rate was 2%. Technique of repair was the only significant risk factor for recurrence with bridge repairs associated with a higher rate of recurrence (P < 0.05). Conclusions. The use of biologic grafts for ventral hernia repair is becoming more popular especially in clean cases. Although followup is limited, there remains a high recurrence rate associated with the use of human acellular dermis.

Diboronic acids as fluorescent probes for cells expressing sialyl Lewis X.

A series of fluorescent diboronic acids was synthesized in nine steps as potential sensors for sialyl Lewis X (sLex). The fluorescent binding studies of these sensors with sLex were carried out in a mixed aqueous solution. Compound 7e was found to show the strongest fluorescence enhancement upon binding with sLex. Using cell cultures, 7e was shown to label sLex-expressing HEPG2 cells at 1 microM, while non-sLex-expressing cells were not labeled.