Implementation of a Patient-Tailored Opioid Prescribing Guideline in Ventral Hernia Surgery.

INTRODUCTION: Opioids are commonly prescribed beyond what is necessary to adequately manage postoperative pain, increasing the likelihood of chronic opioid use, pill diversion, and misuse. We sought to assess opioid utilization and patient-reported outcomes (PROs) in patients undergoing ventral hernia repair (VHR) following the implementation of a patient-tailored opioid prescribing guideline. METHODS: A patient-tailored opioid prescribing guideline was implemented in March of 2018 for patients undergoing inpatient VHR in a large regional healthcare system. We retrospectively assessed opioid utilization and patient-reported outcomes among patients who did (n = 42) and did not receive guideline-based care (n = 121) between March 2018 and December 2019. PROs, operative details, and patient characteristics were extracted from the Abdominal Core Health Quality Collaborative (ACHQC) registry data, and length-of-stay and prescription information were extracted from the electronic health record system at the healthcare institution. RESULTS: The milligram morphine equivalents (MME) prescribed at discharge was lower for patients receiving guideline-based care (Median = 65, interquartile range [IQR] = 50-75) than patients receiving standard care (Median = 100, IQR = 60-150). After adjusting for patient characteristics, the odds of receiving an opioid refill after discharge did not significantly differ between patient groups (P = 0.43). Patient Reported Outcomes Measurement Information System (PROMIS) pain scores and hernia-specific quality-of-life (HerQLes) scores at follow-up also did not differ between patients receiving guideline-based care (Mean PROMIS = 57.3; Mean HerQLes = 53.1) versus those that did not (Mean PROMIS = 56.7; Mean HerQLes = 46.6). CONCLUSIONS: Patients who received tailored, guideline-based opioid prescriptions were discharged with lower opioid dosages and did not require more opioid refills than patients receiving standard opioid prescriptions. Additionally, we found no differences in pain or quality-of-life scores after discharge, indicating the opioids prescribed under the guideline were sufficient for patients.

Laparoscopic versus robotic inguinal hernia repair: 1- and 2-year outcomes from the RIVAL trial.

INTRODUCTION: Robotic inguinal hernia repair is growing in popularity among general surgeons despite little high-quality evidence supporting short- or long-term advantages over traditional laparoscopic inguinal hernia repair. The original RIVAL trial showed increased operative time, cost, and surgeon frustration for the robotic approach without advantages over laparoscopy. Here we report the 1- and 2-year outcomes of the trial. METHODS: This is a multi-center, patient-blinded, randomized clinical study conducted at six sites from 2016 to 2019, comparing laparoscopic versus robotic transabdominal preperitoneal (TAPP) inguinal hernia repair with follow-up at 1 and 2 years. Outcomes include pain (visual analog scale), neuropathic pain (Leeds assessment of neuropathic symptoms and signs pain scale), wound morbidity, composite hernia recurrence (patient-reported and clinical exam), health-related quality of life (36-item short-form health survey), and physical activity (physical activity assessment tool). RESULTS: Early trial participation included 102 patients; 83 (81%) completed 1-year follow-up (45 laparoscopic vs. 38 robotic) and 77 (75%) completed 2-year follow-up (43 laparoscopic vs. 34 robotic). At 1 and 2 years, pain was similar for both groups. No patients in either treatment arm experienced neuropathic pain. Health-related quality of life and physical activity were similar for both groups at 1 and 2 years. No long-term wound morbidity was seen for either repair type. At 2 years, there was no difference in hernia recurrence (1 laparoscopic vs. 1 robotic; P = 1.0). CONCLUSIONS: Laparoscopic and robotic inguinal hernia repairs have similar long-term outcomes when performed by surgeons with experience in minimally invasive inguinal hernia repairs.

Effect of stapled versus layered skin closure on surgical site occurrences after abdominal wall reconstruction.

BACKGROUND: The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure. METHODS: A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized. RESULTS: A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045). CONCLUSION: Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

First report of Pythium myriotylum causing root rot in Cannabis sativa (L.) in California.

In June of 2020 we observed greenhouse grown Cannabis sativa in Sonoma County, CA and Monterey County, CA showing stress symptoms: stunting, leaf chlorosis, and leaf senescence, when moved to flower production conditions. We uprooted symptomatic and healthy plants and observed disease symptoms only in symptomatic plants: reduced root mass, reduced root hair density, and necrosis. Roots and growth substrate samples were taken from infected and healthy plants for further analysis. Approximately one gram of soil was added to 20.0 mL deionized water and 5.0 mL of the resulting slurry was spread on water agar plates. Plates were rinsed free of soil after 24 hours of incubation, then incubated for an additional two days. Diffuse mycelial growth was observed on all soil plates from symptomatic plant pots and not healthy plant pots. Four subcultures were transferred to V8 media and grown for three days. Roots with brown lesions and healthy roots were surface sterilized by soaking in 0.1% sodium hypochlorite for five minutes, rinsed in sterile deionized water, and two-centimeter segments plated on V8 agar. After 24 hours mycelial growth was observed growing from the cut ends of the lesion roots and not the healthy-looking roots. Four subcultures were transferred to V8 and grown for three days. Mycelium from water sample isolates and root isolates were collected and DNA extractions performed using Quick DNA Fungi/Bacterial Kit (Zymo Research Irvine, CA, USA), then PCR amplified using ribosomal internal transcribed spacer (ITS) primers ITS100/ITS4 as described by Riit et al. and cytochrome oxidase I (COX) primers OomCox-Levup/OomCox-Levlo as described by Robideau et al. (Riit et al., 2016; Robideau et al., 2011). Amplicons from all eight isolates for each region were Sanger sequenced and the found to be identical, and consensus sequences deposited in Genebank with accession numbers MW436422 and MW448569 for ITS and COX sequences, respectively. Observation of cultures under light microscope revealed morphological characteristics congruent with P. myriotylum (Watanabe, 2002). Two V8 cultures isolated from roots were cut into approximately 2-3mm2 pieces and transferred to a one-liter flask of water. A negative control using clean V8 was also prepared. The flasks were placed on a rotary shaker and incubated at 150 rpm at ambient temperature for 48 hours. The resulting suspensions for zoospore and control treatments were observed under a light microscope and motile zoospores present in the water suspension from P. myriotylum cultures only. The zoospore suspension was then divided into six equal portions and applied to the soil of six C. sativa rooted cuttings in one-gallon pots. The control slurry was added to two C. sativa rooted cuttings. All plants were grown in a controlled environment for 28 days with 16-hour photoperiod. All plants were then removed from their pots and roots observed for symptoms. Plants that were treated with zoospore suspensions had tan to brown lesions on significant numbers of roots, and reduced root hair density compared to the plants treated with the control V8 agar suspension. Roots samples from all eight plants were then surfaced sterilized in bleach as previously described and five root sections from each plant plated on V8 media. After 48 hours mycelial growth was observed from root sections from P. myriotylum zoospore treated plants and not control plants. DNA extraction and PCR amplification for ITS and COX amplicons was performed from one representative culture for each plant, Sanger sequenced, and aligned with the previous sequences. All ITS and COX sequences were identical to the original sequences from greenhouse samples. P. myriotylum may cause root rot in C. sativa in greenhouse cultivation.

First report of Pythium ultimum causing crown rot in greenhouse grown Cannabis sativa (L.) in California.

In April of 2020 cuttings of Cannabis sativa (L.) in a greenhouse in San Mateo County, CA were observed collapsing, and further observation revealed: water-soaked stems, tan discoloration to the cortex, and discolored roots. The greenhouse irrigation system was supplied by a local stream. We collected one-liter water samples from: intake pond, reservoir tank, irrigation lines, and local potable water tap. Water samples were filtered and plated as described previously (Rollins et al., 2016). Filter papers were removed after 24 hours. Crown sections from four symptomatic plants and one asymptomatic plant were surfaced sterilized in 10% bleach for five minutes, rinsed in sterile deionized water, cut into four-millimeter long sections, and plated onto V8 media, then incubated at room temperature for three days. White mycelial growth was observed from foci within the print of the filter paper from all irrigation water samples but not the potable water supply sample. Similar mycelial growth was observed from plated crown tissue from symptomatic plants only. Observation under light microscope revealed characteristics congruent with P. ultimum, including aseptate hyphae and globose sporangia (Watanabe, 2002). Mycelia was collected for DNA extraction from each of the water and plant sample plates with DNA extractions performed using Quick DNA Fungi/Bacterial Kit (Zymo Research Irvine, CA, USA) and PCR amplified using primers ITS100/ITS4 as described by Riit et al. (2016). All amplicons were Sanger sequenced, aligned using SnapGene software (from GSL Biotech; available at snapgene.com), and compared to barcode referencPe sequences to identify the species using the BarCode of Life Database (BOLDsystems) within the National Center for Biotechnology Information nucleotide database. After trimming and aligning, all amplicons were found to be identical, yielding the 810-nucleotide long consensus ITS amplicon (accession MW114807), which aligned with Pythium ultimum ITS sequences (e.g., accession HQ643886.1) with 100% identity and homology. We then completed Koch's postulates by using pure cultures from root sections of P. ultimum to stem inoculate C. sativa plants. We used a three-millimeter corer to remove a disc of epidermis and applied a plug of pure culture to the wound. We inoculated 10 plants, with two plants mock-inoculated using clean V8 agar. Inoculation sites were wrapped in parafilm, and plants were grown in the greenhouse for 20 days. Stems of mock and oomycete inoculated plants were examined for callus formation and 30 centimeters of stem were excised from each plant. The mock inoculated plants had fully callused inoculation sites and were discolored only where wounded. P. ultimum inoculated plant inoculation sites were partially callused over and had tan discoloration of the cortex that extended 6.0 mm +/- 2.0 mm above and below the inoculation site. Stem segments above and below inoculation sites were surface sterilized and plated on V8 media as previously described and P. ultimum recovered from inoculated plants, confirmed as identical to the inoculum by ITS amplification and sequencing. Mock inoculated plant stem cultures yielded no oomycete growth. Together, these results indicate that P. ultimum has the ability to cause crown rot in C. sativa in greenhouse cultivation.

Reducing Length of Stay Using a Robotic-assisted Approach for Retromuscular Ventral Hernia Repair: A Comparative Analysis From the Americas Hernia Society Quality Collaborative.

OBJECTIVE: The aim of this study was to compare length of stay (LOS) after robotic-assisted and open retromuscular ventral hernia repair (RVHR). BACKGROUND: RVHR has traditionally been performed by open techniques. Robotic-assisted surgery enables surgeons to perform minimally invasive RVHR, but with unknown benefit. Using real-world evidence, this study compared LOS after open (o-RVHR) and robotic-assisted (r-RVHR) approach. METHODS: Multi-institutional data from patients undergoing elective RVHR in the Americas Hernia Society Quality Collaborative between 2013 and 2016 were analyzed. Propensity score matching was used to compare median LOS between o-RVHR and r-RVHR groups. This work was supported by an unrestricted grant from Intuitive Surgical, and all clinical authors have declared direct or indirect relationships with Intuitive Surgical. RESULTS: In all, 333 patients met inclusion criteria for a 2:1 match performed on 111 r-RVHR patients using propensity scores, with 222 o-RVHR patients having similar characteristics as the robotic-assisted group. Median LOS [interquartile range (IQR)] was significantly decreased for r-RVHR patients [2 days (IQR 2)] compared with o-RVHR patients [3 days (IQR 3), P < 0.001]. No differences in 30-day readmissions or surgical site infections were observed. Higher surgical site occurrences were noted with r-RVHR, consisting mostly of seromas not requiring intervention. CONCLUSIONS: Using real-world evidence, a robotic-assisted approach to RVHR offers the clinical benefit of reduced postoperative LOS. Ongoing monitoring of this technique should be employed through continuous quality improvement to determine the long-term effect on hernia recurrence, complications, patient satisfaction, and overall cost.

Standard laparoscopic versus robotic retromuscular ventral hernia repair.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) demonstrates comparable recurrence rates, but lower incidence of surgical site infection (SSI) than open repair. Delayed complications can occur with intraperitoneal mesh, particularly if a subsequent abdominal operation is required, potentially resulting in bowel injury. Robotic retromuscular ventral hernia repair (RRVHR) allows abdominal wall reconstruction (AWR) and extraperitoneal mesh placement previously only possible with open repair, with the wound morbidity of LVHR. METHODS: All LVHR and RRVHR performed in our institution between June 2013 and May 2015 contained in the Americas Hernia Society Quality Collaborative database were analyzed. Continuous bivariate analysis was performed with Student's t test. Continuous nonparametric data were compared with Chi-squared test, or Fisher's exact for small sample sizes. p values <0.05 were considered significant. RESULTS: We compared 103 LVHR with 53 RRVHR. LVHR patients were older (60.2 vs. 52.9 years; p = 0.001), but demographics were otherwise similar between groups. Hernia width was similar (6.9 vs. 6.5 cm, p = 0.508). Fascial closure was achieved more often with RRVHR (96.2 vs. 50.5 %; p < 0.001) and aided by myofascial release in 43.4 %. Mesh was placed in an intraperitoneal position in 90.3 % of LVHR and extraperitoneal in 96.2 % of RRVHR. RRVHR operative time was longer (245 vs. 122 min, p < 0.001). Narcotic requirement was similar between LVHR and RRVHR (1.8 vs. 1.4 morphine equivalents/h; p = 0.176). Seroma was more common after RRVHR (47.2 vs. 16.5 %, p < 0.001), but SSI was similar (3.8 vs. 1 %, p = 0.592). Median length of stay was shorter after RRVHR (1 vs. 2 days, p = 0.004). Direct hospital cost was similar (LVHR $13,943 vs. RRVHR $19,532; p = 0.07). CONCLUSION: RRVHR enables true AWR, with myofascial release to offset tension for midline fascial closure, and obviates the need for intraperitoneal mesh. Perioperative morbidity of RRVHR is comparable to LVHR, with shorter length of stay despite a longer operative time and extensive tissue dissection.

Risks of subsequent abdominal operations after laparoscopic ventral hernia repair.

INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) with intraperitoneal mesh placement is well established; however, the fate of patients requiring future abdominal operations is not well understood. This study identifies the characteristics of LVHR patients undergoing reoperation and the sequelae of reoperation. METHODS: A retrospective review of a prospectively maintained database at a hernia referral center identified patients who underwent LVHR between 2005 and 2014 and then underwent a subsequent abdominal operation. The outcomes of those reoperations were collected. Data are presented as a mean with ranges. RESULTS: A total of 733 patients underwent LVHR. The average age was 56.5 years, BMI 33.9 kg/m2, hernia size 115 cm2 (range 1-660 cm2), and mesh size 411 cm2 (range 17.7-1360 cm2). After a mean follow-up of 19.4 months, the overall hernia recurrence rate was 8.4 %. Subsequent abdominal operations were performed in 17 % (125 patients) at a mean 2.2 years. The most common indication for reoperation was recurrent hernia (33 patients, 26.4 %), followed by bowel obstruction (18 patients, 14.4 %), hepatopancreaticobiliary (17 patients, 13.6 %) and infected mesh removal (15 patients, 12 %), gynecologic (10 patients, 8 %), colorectal (8 patients, 6.4 %), bariatric (4 patients, 3 %), trauma (1 patient, 0.8 %), and other (19 patients, 15 %). The overall incidence of enterotomy or unplanned bowel resection (EBR) at reoperation was 4 %. This occurred exclusively in those reoperated for complete bowel obstruction, and the reason for EBR was mesh-bowel adhesions. No other indication for reoperation resulted in EBR. The incidence of secondary mesh infection after subsequent operation was 2.4 %. CONCLUSION: In a large consecutive series of LVHR, the rate of abdominal reoperation was 17 %. Generally, these reoperations can be performed safely. A reoperation for bowel obstruction, however, may carry an increased risk of EBR as a direct result of mesh-bowel adhesions. Secondary mesh infection after reoperation, although rare, may also occur. Surgeons should discuss with their patients the potential long-term implications of having an intraperitoneal mesh and how it may impact future abdominal surgery.

Superiority of Roeder's Knot for Fascial Mesh Fixation in a Cadaveric Model.

OBJECTIVE: This study compares the use of Roeder's knot (1:3:1, 1 hitch, 3 winds, and 1 locking hitch) to the surgeon's knot regarding the security of the knot and predictability of its position. METHOD: A polypropylene mesh was secured to the undersurface of the abdominal wall of a fresh frozen cadaver using tacks. Eight standardized transfascial sutures were performed. Four of them were secured with surgeon's knot and the remaining 4 were tied with Roeder's knot. A Mosquito hemostat was placed between the mesh and the stitch loop and the distance between its jaws was measured. We then created subcutaneous flap and measured the vertical distance between the knot and the anterior sheath. RESULTS: When surgeon's knot was used, the distance between the mesh and the stitch loop ranged between 4 and 6 mm. This distance could not be measured when Roeder's knot was used due to inability to place hemostat between the mesh and the stitch loop. The vertical length between the anterior sheath and the surgeon knot ranged between 3 and 13 mm while remaining consistent at 2 mm when Roeder's knot was applied. CONCLUSIONS: This study shows that Roeder's knot is superior to the regular sliding knot in securing the mesh to the abdominal wall. It can be tightened appropriately and leads to less variation when used properly. It has many other applications that stem from its ability to be advanced with different degrees of tightness based on body habitus and the operative requirements.

The Assessment of Total Energy Expenditure During a 14-Day In-Season Period of Professional Rugby League Players Using the Doubly Labelled Water Method.

Rugby League is a high-intensity collision sport competed over 80 min. Training loads are monitored to maximize recovery and assist in the design of nutritional strategies although no data are available on the total energy expenditure (TEE) of players. We therefore assessed resting metabolic rate (RMR) and TEE in six Super League players over 2 consecutive weeks in-season including one game per week. Fasted RMR was assessed followed by a baseline urine sample before oral administration of a bolus dose of hydrogen (deuterium 2H) and oxygen (18O) stable isotopes in the form of water (2H218O). Every 24 hr thereafter, players provided urine for analysis of TEE via DLW method. Individual training load was quantified using session rating of perceived exertion (sRPE) and data were analyzed using magnitude-based inferences. There were unclear differences in RMR between forwards and backs (7.7 ± 0.5 cf. 8.0 ± 0.3 MJ, respectively). Indirect calorimetry produced RMR values most likely lower than predictive equations (7.9 ± 0.4 cf. 9.2 ± 0.4 MJ, respectively). A most likely increase in TEE from Week 1 to 2 was observed (17.9 ± 2.1 cf. 24.2 ± 3.4 MJ) explained by a most likelyincrease in weekly sRPE (432 ± 19 cf. 555 ± 22 AU), respectively. The difference in TEE between forward and backs was unclear (21.6 ± 4.2 cf. 20.5 ± 4.9 MJ, respectively). We report greater TEE than previously reported in rugby that could be explained by the ability of DLW to account for all match and training-related activities that contributes to TEE.

Open preperitoneal inguinal hernia repair has superior 1-year patient-reported outcomes compared to Shouldice non-mesh repair.

INTRODUCTION: The Shouldice method for inguinal hernia repair remains the gold standard for prosthesis-free repairs. Nonetheless, international guidelines have favored posterior mesh reinforcement as the standard of care for inguinal hernia repair due to lower risk of recurrence and chronic pain, avoidance of general anesthesia, and favorable biomechanical properties. Recent publications have shown the benefits of an open approach to posterior repairs. Herein, we use the Abdominal Core Health Quality Collaborative (ACHQC) registry to compare patient-reported outcomes after a Shouldice no-mesh repair versus open preperitoneal (OPP) mesh repair. METHODS: We performed a propensity score matched analysis to compare patient-reported quality of life (QoL) and peri/postoperative outcomes after a Shouldice repair versus OPP. Data from 2012 to 2022 were obtained from the ACHQC, and 1:1 optimal matching was performed. EuraHS scores were used to estimate QoL, and further analysis on the EuraHS domains of pain, aesthetics, and activity restriction were performed between the two cohorts. RESULTS: Matching resulted in 257 participants in each, Shouldice and OPP cohorts. OPP was associated with a better QoL score compared to Shouldice at 30 days after surgery (Median (IQR) 7.75 (2.0-17.0) vs 13.0 (4.0-26.1); OR 0.559 [0.37, 0.84]; p = 0.003). This difference persisted at 6 months and 1 year postoperatively (OR 0.447 [0.26, 0.75] and 0.492 [0.26, 0.93], respectively). We did not observe any significant differences in hernia recurrence risk at 1-year, or rates of 30-day SSOs/SSIs, postoperative bleeding, peripheral nerve injury, DVTs, or UTIs. CONCLUSION: Our data suggest that OPP is associated with significantly better patient-reported QoL, in the first month after surgery and up to 1 year postoperatively, especially with respect to lesser pain, when compared to the Shouldice repair. In specialized inguinal hernia practices, open posterior mesh repairs may lead to better outcomes than non-mesh repairs. We encourage more training in both repairs to facilitate larger prospective studies and evaluation of the generalizability of these results to all surgeons performing IHR.

Reducing the incidence of surgical site infection after ventral hernia repair: Outcomes from the RINSE randomized control trial.

BACKGROUND: The clinical and financial impact of surgical site infection after ventral hernia repair is significant. Here we investigate the impact of dual antibiotic irrigation on SSI after VHR. METHODS: This was a multicenter, prospective randomized control trial of open retromuscular VHR with mesh. Patients were randomized to gentamicin â€‹+ â€‹clindamycin (G â€‹+ â€‹C) (n â€‹= â€‹125) vs saline (n â€‹= â€‹125) irrigation at time of mesh placement. Primary outcome was 30-day SSI. RESULTS: No significant difference was seen in SSI between control and antibiotic irrigation (9.91 vs 9.09 â€‹%; p â€‹= â€‹0.836). No differences were seen in secondary outcomes: SSO (11.71 vs 13.64 â€‹%; p â€‹= â€‹0.667); 90-day SSO (11.1 vs 13.9 â€‹%; p â€‹= â€‹0.603); 90-day SSI (6.9 vs 3.8 â€‹%; p â€‹= â€‹0.389); SSIPI (7.21 vs 7.27 â€‹%, p â€‹= â€‹0.985); SSOPI (3.6 vs 3.64 â€‹%; p â€‹= â€‹0.990); 30-day readmission (9.91 vs 6.36 â€‹%; p â€‹= â€‹0.335); reoperation (5.41 vs 0.91 â€‹%; p â€‹= â€‹0.056). CONCLUSION: Dual antibiotic irrigation with G â€‹+ â€‹C did not reduce the risk of surgical site infection during open retromuscular ventral hernia repair.

Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula.

The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.

Robotic repair of non-midline hernias.

Non-midline abdominal wall hernias present unique anatomic challenges, making repair more complex. The constraints of the peritoneal cavity, pelvis, and costal margin limit the utility of intraperitoneal mesh repair, and extra-peritoneal repairs have traditionally been performed using open techniques, often resulting in higher wound morbidity. Advances in minimally invasive surgery make visualization and dissection of such complex cases feasible, with all the attendant benefits of a minimally invasive over an open approach. In this study, we examined the use of the robotic platform to repair non-midline hernias. Retrospective review of all non-midline abdominal wall hernias was performed robotically at Prisma Health, excluding parastomal hernias. Study conducted and outcomes reported according to STROBE statement. Repair was performed in the retro-rectus (n = 3) or retro-rectus + transversus abdominis release (TAR) (n = 39), pre-peritoneal (n = 22), and intraperitoneal (n = 1). Mean hernia width was 9.4 cm, permanent synthetic mesh used for all repairs. Mean LOS was 1.5 days. Surgical-site occurrence (SSO) occurred in 49.2%, 78% of which were simple seroma. Three patients (4.6%) developed surgical-site infection (SSI). Two recurrences were identified with a mean follow-up of 11 mos. The robotic platform facilitates complex dissection to allow minimally invasive, extra-peritoneal repair of complex non-midline hernias. This approach overcomes the anatomic constraints of intraperitoneal mesh repair and the wound morbidity of open repair.

Improved patient-reported outcomes after open preperitoneal inguinal hernia repair compared to anterior Lichtenstein repair: 10-year ACHQC analysis.

INTRODUCTION: The Lichtenstein repair has been synonymous with "open" inguinal hernia repair (IHR) for 40 years. However, international guidelines have suggested that posterior mesh placement results in advantageous biomechanics and reduced risk of nerve-related chronic pain. Additionally, the use of local anesthetics has been shown to reduce postoperative pain and complication risks. An open transrectus preperitoneal/open preperitoneal (TREPP/OPP) repair combines posterior mesh placement with the use of local anesthetic and as such could be the ideal repair for primary inguinal hernia. Using the Abdominal Core Health Quality Collaborative (ACHQC) registry, we compared open anterior mesh with open posterior mesh repairs. METHODS: We performed a propensity score matched analysis of patients undergoing open IHR between 2012 and 2022 in the ACHQC. After 1:1 optimal matching, both the TREPP/OPP and Lichtenstein cohorts were balanced with 451 participants in each group. Outcomes included patient-reported quality of life (QoL), hernia recurrence, and postoperative opioid use. RESULTS: Improvement was seen after TREPP/OPP in EuraHS QoL score at 30 days (OR 0.558 [0.408, 0.761]; p = 0.001), and the difference persisted at 1 year (OR 0.588 [0.346, 0.994]; p = 0.047). Patient-reported opioid use at 30-day follow-up was significantly lower in the TREPP/OPP cohort (OR 0.31 [0.20, 0.48]; p < 0.001). 30-day frequency of surgical-site occurrences was significantly higher in the Lichtenstein repair cohort (OR 0.22 [0.06-0.61]; p = 0.007). There were no statistically significant differences in hernia recurrence risk at 1 year, or rates of postoperative bleeding, peripheral nerve injury, DVTs, or UTIs. CONCLUSION: Our analysis demonstrates a benefit of posterior mesh placement (TREPP/OPP) over anterior mesh placement (Lichtenstein) in open inguinal hernia repair in patient-reported QoL and reduced opioid use.

Naturally Occurring Triploidy in Cannabis.

Polyploidy is a significant evolutionary process in plants that involves the duplication of genomic content and has been recognized as a key mechanism driving plant diversification and adaptation. In natural populations, polyploids frequently arise from unreduced gametes, which subsequently fuse with reduced or unreduced gametes, resulting in triploid or tetraploid offspring, respectively. Cannabis sativa L. is a diploid species, but recent work using artificially induced polyploidy has demonstrated its potential advantages in an agricultural setting. Further, recent work has identified that some elite clonal cultivars, vis. Mac1, are triploid, with no indication that they were artificially produced. The current study was conducted to determine if polyploidy is a naturally occurring phenomenon in cannabis and to estimate the frequency of this phenomenon across populations. To do this, the presence of natural triploid individuals was evaluated in 13 seedling populations of cannabis using a flow cytometry analysis. Among the examined populations, natural triploids were identified in 10 groups with an average frequency of approximately 0.5%. The highest frequency of natural triploids was observed in a self-pollinated population at 2.3%. This research demonstrates that polyploidy is a naturally occurring event in cannabis and triploids are present at an average of approximately 0.5%, or 1 in 200 plants. These data shed light on the natural variation in ploidy within cannabis populations and contribute valuable insights to the understanding of cannabis genetics and breeding practices.

Rectus to defect ratio for estimating the complexity of ventral hernia repair: Is it reliable for robotic surgery?

INTRODUCTION: The rectus to defect ratio (RDR) has been previously described as a metric which enables surgeons to estimate the need to perform additional myofascial release (AMR), in addition to open Rives-Stoppa retro-muscular hernia repair. We sought to validate this measurement specifically for patients undergoing robotic totally extraperitoneal (eTEP) hernia repair. METHODS: A retrospective chart review of 188 patients who underwent robotic ventral hernia repair via eTEP approach. RDR on preoperative CT was compared to the final operation rendered. The primary endpoint was the RDR's ability to predict the need for TAR to achieve fascial closure. RESULTS: Of 188 patients, 154 were repaired with rectus myofascial release, while 34 also required TAR. There was a linear decrease in the need for TAR with increasing RDR. RDR 1-1.49 (n â€‹= â€‹12) required TAR in 66.7 â€‹% of cases, RDR 1.5-1.99 (n â€‹= â€‹25) in 43.8 â€‹%, RDR 2-2.49 (n â€‹= â€‹31) in 29 â€‹%, and RDR >2.5 (n â€‹= â€‹151) in just 5.8 â€‹% CONCLUSION: The RDR accurately predicts the need for TAR to achieve fascial closure during robotic eTEP ventral hernia repair. An RDR >2.5 portends fascial closure without TAR 94.2 â€‹% of cases.

Outcomes of subsequent abdominal operations after an initial ventral hernia repair.

INTRODUCTION: Nearly 20% of ventral hernia repair (VHR) patients require a subsequent abdominal operation (SAO), and mesh position may impact the complexity and outcome of the SAO. METHODS: Retrospective review of VHR with mesh from 2006 to 2020 from an internal database and the ACHQC. Primary outcomes measured incidence, complexity, and complications of SAO relative to mesh position. RESULTS: SAO was required in 433 of 2539 (17.1%) patients, totaling 671 operations; 197/893 (22.1%) with intraperitoneal mesh (IPM) and 236/1646 (14.3%) with extraperitoneal mesh (EPM; p â€‹< â€‹0.001). SAO was directly related to VHR in 180 (232 total SAOs) and unrelated in 253 (439 total SAOs). There were no significant differences in complications after SAO between IPM and EPM, nor any difference in adhesion complexity. CONCLUSION: Incidence of SAO is higher with IPM, but surgical outcomes are similar. Due to the risk of secondary mesh infection with IPM, significantly more of these were removed at the time of SAO.

Impact of methocarbamol on opioid use after ventral incisional hernia repair.

BACKGROUND: Alternatives to opioid analgesia are needed to reduce the risk of abuse, misuse, and diversion. Musculoskeletal pain is a significant contributor to postoperative pain after ventral hernia repair (VHR). We report the impact of methocarbamol on opioid prescribing after VHR. METHODS: Review of all robotic and open VHR, Jan 2020-July 2022. Data was collected in the Abdominal Core Health Quality Collaborative (ACHQC) with additional chart review to assess for opioid refills. A 2:1 propensity score match was performed comparing opioid prescribing in patients prescribed vs not prescribed methocarbamol. RESULTS: 101 patients received methocarbamol compared with 202 without. Similar number of patients received an opioid prescription (87.1 vs 86.6%; p = 0.904). Study patients received significantly lower MME prescription at discharge (60 v 75; p = 0.021) with no difference in refills (12.5 vs 16.6%; p = 0.386). CONCLUSION: Addition of methocarbamol to a multimodal analgesic regimen after VHR facilitates reduction in prescribed opioid with no increase in refills.