Computed tomography imaging in ventral hernia repair: can we predict the need for myofascial release?

INTRODUCTION: Currently, the need for additional myofascial release (AMR) in addition to retromuscular dissection during open Rives-Stoppa hernia repair is determined intraoperatively based on the discretion of the surgeon. We developed a novel method to objectively predict the need for AMR preoperatively using computed tomography (CT)-measured rectus width to hernia width ratio (RDR). METHODS: A retrospective chart review of all patients who underwent open retro-muscular mesh repair of midline ventral hernia between August 1, 2007 and February 1, 2018, who had a preoperative CT scan within 1 year prior to their operation. The primary endpoint was the ability of the defect ratio to predict the need for AMR in pursuit of fascial closure. The secondary endpoint was the ability of Component Separation Index (CSI) to predict the need for AMR to obtain fascial closure. RESULTS: Of 342 patients, 208 repaired with rectus abdominis release alone (RM group), while 134 required AMR (RM + group). An RDR of > 1.34 on area under the curve analysis predicted the need for AMR with 77.6% accuracy. There was a linear decrease in the need for AMR with increasing RDR: RDR < 1 required AMR in 78.8% of cases, RDR 1.1-1.49 in 52%, RDR 1.5-1.99 in 32.1%, and RDR > 2 in just 10.8%. Similarly, CSI > 0.146 predicted the need for AMR with 76.3% accuracy on area under the curve analysis. CONCLUSION: The RDR is a practical and reliable tool to predict the ability to close the defect during open Rives-Stoppa ventral hernia repair without AMR. An RDR of > 2 portends fascial closure with rectus abdominis myofascial release alone in 90% of cases.

Prophylactic mesh augmentation using permanent synthetic mesh: outcomes of keyhole and Stapled Ostomy Reinforcement with Retromuscular Mesh techniques.

INTRODUCTION: Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH. METHODS: This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24). RESULTS: PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195). CONCLUSION: Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.

Primary thoracoabdominal hernias.

BACKGROUND: Primary thoracoabdominal hernias involve the triad of an intercostal hernia, abdominal wall hernia, and diaphragmatic hernia. We report a case series of this rare entity and describe the evolution and outcomes. METHODS: We completed a retrospective analysis of thoracoabdominal hernia repairs performed January 2010-April 2019 at Prisma Health-Upstate and Carolinas Medical Center. This includes all patients with spontaneous defects, excluding incisional hernias or those resulting from external trauma. RESULTS: Of 16 patients with thoracoabdominal hernias, 15 patients developed hernias after forceful coughing and one patient developed a hernia after strenuous physical activity. Seven patients required at least one additional intervention; two for recurrence; two for recurrence of original intercostal repairs done elsewhere; two for wound complications; and one had a missed abdominal wall component. CONCLUSIONS: Primary thoracoabdominal hernias require a high index of suspicion. Durable repair involves complex reconstruction of the thoracoabdominal wall including the diaphragm, intercostal space, rib fracture fixation, and mesh reinforcement of the abdominal wall with permanent fixation constructs.

45-year-old man • fever • generalized rash • recent history of calcaneal osteomyelitis • Dx?

► Fever ► Generalized rash ► Recent history of calcaneal osteomyelitis.

Anti-inflammatory coating of hernia repair meshes: a 5-rabbit study.

PURPOSE: Polymeric mesh implantation has become the golden standard in hernia repair, which nowadays is one of the most frequently performed surgeries in the world. However, many biocompatibility issues remain to be a concern for hernioplasty, with chronic pain being the most notable post-operative complication. Oxidative stress appears to be a major factor in the development of those complications. Lack of material inertness in vivo and oxidative environment formed by inflammatory cells result in both mesh deterioration and slowed healing process. In a pilot in vivo study, we prepared and characterized polypropylene hernia meshes with vitamin E (α-tocopherol)-a potent antioxidant. The results of that study supported the use of vitamin E as potential coating to alleviate post-surgical inflammation, but the pilot nature of the study yielded limited statistical data. The purpose of this study was to verify the observed trend of the pilot study statistically. METHODS: In this work, we conducted a 5-animal experiment where we have implanted vitamin E-coated and uncoated control meshes into the abdominal walls of rabbits. Histology of the mesh-adjacent tissues and electron microscopy of the explanted mesh surface were conducted to characterize host tissue response to the implanted meshes. RESULTS: As expected, modified meshes exhibited reduced foreign body reaction, as evidenced by histological scores for fatty infiltrates, macrophages, neovascularization, and collagen organization, as well as by the surface deterioration of the meshes. CONCLUSION: In conclusion, results indicate that vitamin E coating reduces inflammatory response following hernioplasty and protects mesh material from oxidative deterioration.

Molecular characterization of Trypanosoma (Megatrypanum) spp. infecting cattle (Bos taurus), white-tailed deer (Odocoileus virginianus), and elk (Cervus elaphus canadensis) in the United States.

In the United States, the generally non-pathogenic trypanosome of cattle is designated Trypanosoma (Megatrypanum) theileri and is distinguished morphologically from Trypanosoma (M.) cervi, a trypanosome originally described in mule deer and elk. Phylogenetic studies of the Megatrypanum trypanosomes using various molecular markers reveal two lineages, designated TthI and TthII, with several genotypes within each. However, to date there is very limited genetic data for T. theileri, and none for the Megatrypanum trypanosomes found in wild ungulates, in the U.S. In this study U.S. isolates from cattle (Bos taurus), white-tailed deer (Odocoileus virginianus) (WTD), and elk (Cervus elaphus canadensis) were compared by ribosomal DNA (rDNA) sequence analysis and their incidence in cattle and WTD in south Texas counties was investigated. Phylogenetic analyses showed clear separation of the bovine and cervine trypanosomes. Both lineages I and II were represented in the U.S. cattle and WTD parasites. Lineage I cattle isolates were of a previously described genotype, whereas WTD and elk isolates were of two new genotypes distinct from the cattle trypanosomes. The cattle isolate of lineage II was of a previously reported genotype and was divergent from the WTD isolate, which was of a new genotype. In La Salle, Starr, Webb, and Zapata counties in south Texas a total of 51.8% of white-tailed deer were positive for trypanosomes by 18S rDNA PCR. Of the cattle screened in Webb County, 35.4% were positive. Drought conditions prevailing in south Texas when the animals were screened suggest the possibility of a vector for Trypanosoma other than the ked (Lipoptena mazamae) and tabanid flies (Tabanus spp. and Haematopota spp.).

Management of complications after laparoscopic Roux-en-Y gastric bypass.

Obesity has become an increasing problem in developed countries and laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the leading treatments for this disease. Although studies show that it is effective in reducing weight and lessening comorbidities, both early and late complications can occur. Early complications include venous thromboembolism, anastomotic leak, and hemorrhage. Late complications include obstruction, anastomotic stenosis, fistula, ulcer, cholelithiasis and nutritional deficiencies. Diagnosis of these complications is often challenging due to the lack of specificity of the presenting signs and symptoms. A high index of suspicion for detecting these complications is universally advocated. Fortunately, mortality from this procedure is rare. Management of the complications is generally consistent with basic surgical principles and surgical reinterventions can often be performed either endoscopically or laparoscopically depending on the situation and the surgeon's expertise. The available literature is confounded by mixing of results between open and laparoscopic techniques as well as the substantial differences in technique between authors reporting their outcomes. Although there is no consensus for managing the reported complications of LRYGB surgery, this article reviews the current literature and describes the presentation, diagnosis, and management of each of the early and late complications associated with the procedure.

Mesh terminology 101.

In any collaborative endeavor, when fields like medicine and bioengineering overlap, the proper use of technical vocabulary takes on added importance. It is important that scientists and clinicians, while coming from different backgrounds and educational systems, agree upon and utilize a common language based on mutually understood concepts and definitions. Regarding biomaterial testing applications, numerous terms are used to describe a wide variety of material behaviors when test specimens are subjected to mechanical, chemical, electrical and thermal stressors. In this discussion we will limit ourselves to the mechanical properties of materials which are utilized for soft tissue or fascial-based repairs. Following a literature search combining the keywords surgical mesh and biomaterials testing, common terms used to describe the mechanical properties of mesh were selected. Our analysis seeks to define the following terms and describe their applicability within the context of biomaterials for hernia repair: elasticity, stiffness, flexibility, tensile strength, distension, deformation, bending stiffness, and compliance. Unfortunately, in the technical literature, terms are often altered or extrapolated without adequate explanation. In other cases, related but technically different terms are mistakenly used interchangeably. With the mounting interest in biomaterials for the use in repair of abdominal wall defects, there is a need to standardize the terminology used to describe the biomechanical properties of mesh.

Bone anchor mesh fixation for complex laparoscopic ventral hernia repair.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) has gained wide acceptance by both surgeons and patients, but hernias that approach a bony prominence are more complex due to the difficulty of proper fixation. This study was conducted to evaluate the use of bone anchor mesh fixation for complex LVHR. METHODS: A prospective study of patients having complex LVHR with bone anchors was conducted using patients from 2 academic institutions between July 2003 and December 2007. Patient demographic data, characteristics of the hernia, operative details, and postoperative outcomes were recorded. RESULTS: A total of 30 patients who had LVHR using bone anchors were evaluated (20 women, 10 men; mean age 60.9 years, range 41-83 years). In all, 17 suprapubic and 13 lateral hernias were included, requiring a mean of 2.8 and 3.2 bone anchors, respectively. The average hernia defect was 263 cm(2) (range 35-690 cm(2)), and the average mesh size was 663 cm(2) (range 255-1360 cm(2)). Mean operative time was 218 minutes (range 98-420 minutes), with an estimated blood loss of 46 mL (range 10-100 mL). The average length of stay was 5.2 days (range 1-26 days). Seven patients (23.3%) developed postoperative complications, and 1 patient in this study died (mortality 3.3%). During follow-up of 13.2 months (range 1-26 months), 2 patients (6.7%) developed a recurrent hernia. CONCLUSIONS: Bone anchors can be used successfully in the laparoscopic repair of complex ventral hernias, particularly with suprapubic and lateral hernias that approach a bony prominence. The complication rate is acceptable, with a short hospital stay and low recurrence rate.

Posterior components separation during retromuscular hernia repair.

BACKGROUND: Retromuscular ventral hernia repair with mesh is a durable technique. In this paper, we describe a novel technique which allows for significant mesh overlap via the retromuscular space in cases of massive ventral hernia. METHODS: The retromuscular space is developed laterally, to the edge of the rectus sheath. The posterior rectus sheath is incised, dividing the posterior aponeurosis of the internal oblique. The dissection is carried out laterally between the internal oblique and the transversus abdominis muscle, creating space for a large mesh underlay. RESULTS: We have performed this technique successfully in 20 patients with a mean defect area of 223 cm(2) and a mean mesh area of 698 cm(2). Three patients developed wound complications and none complained of long-term pain or abdominal wall deformity. There has been one recurrence due to technical error after a mean 12-month follow-up. CONCLUSION: This technique of dissection between the internal oblique and transversus abdominis muscles allows for the closure of large hernia defects. The mechanism is two-fold: (1) mobility for closure of the posterior rectus sheath, dorsal to the prosthetic; and (2) increased mobility of the rectus, internal, and external obliques, allowing reconstruction of the linea alba.

Plant pathogen forensics: capabilities, needs, and recommendations.

A biological attack on U.S. crops, rangelands, or forests could reduce yield and quality, erode consumer confidence, affect economic health and the environment, and possibly impact human nutrition and international relations. Preparedness for a crop bioterror event requires a strong national security plan that includes steps for microbial forensics and criminal attribution. However, U.S. crop producers, consultants, and agricultural scientists have traditionally focused primarily on strategies for prevention and management of diseases introduced naturally or unintentionally rather than on responding appropriately to an intentional pathogen introduction. We assess currently available information, technologies, and resources that were developed originally to ensure plant health but also could be utilized for postintroduction plant pathogen forensics. Recommendations for prioritization of efforts and resource expenditures needed to enhance our plant pathogen forensics capabilities are presented.

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair.

INTRODUCTION: Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. METHODS: All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. RESULTS: Twelve patients (11 male and 1 female) with a mean age of 41 years (range 29-51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6 weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. CONCLUSIONS: A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.

Laparoscopic ventral hernia repair: a single center experience.

A retrospective chart review at the Carolinas Medical Center was performed on all patients who underwent laparoscopic ventral hernia repair (LVHR) from July 1998 through December 2003. LVHR was successfully completed in 270 of the 277 patients, or 98%, in whom it was attempted. Half of the patients (138/277) had at least one previous failed repair. The average defect measured 143.3 cm(2), and mesh was used in all repairs. The mean operating time was 168.3 min, mean blood loss was 50 cc, and average length of hospitalization was 3.0 days. Thirty-four complications occurred in 31 patients (11%). Only two mesh infections occurred (0.7%). At a mean follow-up period of 21 months, the rate of hernia recurrence was 4.7%. As experience grows and length of follow-up expands, LVHR may become the preferred approach for ventral hernia in difficult patients, especially obese patients and patients who have failed prior open repairs.

Do patient or hospital demographics predict cholecystectomy outcomes? A nationwide study of 93,578 patients.

BACKGROUND: The purpose of this study was to examine the influence of patient and hospital demographics on cholecystectomy outcomes. METHODS: Year 2000 data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was obtained for all patients undergoing inpatient cholecystectomy at 994 nationwide hospitals. Differences (p < 0.05) were determined using standard statistical methods. RESULTS: Of 93,578 cholecystectomies performed, 73.4% were performed laparoscopically. Length of hospital stay (LOS), charges, morbidity, and mortality were significantly less for laparoscopic cholecystectomy (LC). Increasing patient age was associated with increased LOS, charges, morbidity, mortality, and a decreased LC rate. Charges, LOS, morbidity, and mortality were highest for males with a lower LC rate than for females Mortality and LOS were higher, whereas morbidity was lower for African Americans than for whites. Hispanics had the shortest LOS, as well as the lowest morbidity and mortality rates. Laparoscopic cholecystectomy was performed more commonly for Hispanics than for whites or African Americans, with lower charges for whites. Medicare-insured patients incurred longer LOS as well as higher charges, morbidity, and mortality than Medicaid, private, and self-pay patients, and were the least likely to undergo LC. As median income decreases, LOS increases, and morbidity decreases with no mortality effect. Teaching hospitals had a longer LOS, higher charges, and mortality, and a lower LC rate, with no difference in morbidity, than nonteaching centers. As hospital size (number of beds) increased, LOS, and charges increased, with no difference in morbidity. Large hospitals had the highest mortality rates and the lowest incidence of LC. Urban hospitals had higher LOS and charges with a lower LC rate than rural hospitals. After control was used for all other covariates, increased age was a predictor of increased morbidity. Female gender, LC, and intraoperative cholangiogram all predicted decreased morbidity. Increased age, complications, and emergency surgery predicted increased mortality, with laparoscopy and intraoperative cholangiogram having protective effects. Patient income, insurance status, and race did not play a role in morbidity or mortality. Academic or teaching status of the hospital also did not influence patient outcomes. CONCLUSIONS: Patient and hospital demographics do affect the outcomes of patients undergoing inpatient cholecystectomy. Although male gender, African American race, Medicare-insured status, and large, urban hospitals are associated with less favorable cholecystectomy outcomes, only increased age predicts increased morbidity, whereas female gender, laparoscopy, and cholangiogram are protective. Increased age, complications, and emergency surgery predict mortality, with laparoscopy and intraoperative cholangiogram having protective effects.

Cirrhosis is not a contraindication to laparoscopic surgery.

BACKGROUND: Cirrhosis of the liver contributes significantly to morbidity and mortality in abdominal surgery. The proven benefits of laparoscopy seem especially applicable to patients with this complex disease. This study evaluates the safety and efficacy of laparoscopic procedures in a series of consecutively treated patients with biopsy-proven cirrhosis. METHODS: The medical records of all patients with biopsy-proven cirrhosis undergoing laparoscopic surgery at the authors' medical center between January 2000 and December 2003 were retrospectively reviewed. RESULTS: A total of 50 patients (27 men and 23 women) underwent 52 laparoscopic procedures. Among these 50 patients were 39 patients with Child-Pugh classification A cirrhosis, 10 with classification B, and 1 with classification C, who underwent a variety of laparoscopic procedures including cholecystectomy (n = 22), splenectomy (n = 18), colectomy (n = 4), diagnostic laparoscopy (n = 3), ventral hernia repair (n = 1), Nissen fundoplication (n = 1), Heller myotomy (n = 1), Roux-en-Y gastric bypass (n = 1), and radical nephrectomy (n = 1). There were two conversions (4%) to an open procedure. The mean operative time was 155 min. Estimated blood loss averaged 124 ml for all procedures, and 20 patients (40%) required perioperative transfusion of blood products. One patient required a single blood transfusion postoperatively because of anemia. No one experienced hepatic decompensation. Overall morbidity was 16%. There were no deaths. The mean length of hospitalization was 3 days. CONCLUSIONS: Although technically challenging because portal hypertension, varices, and thrombocytopenia frequently coexist, basic and advanced laparoscopic procedures are safe for patients with mild to moderate cirrhosis of the liver.

The laparoscopic repair of suprapubic ventral hernias.

BACKGROUND: The complexity of dissection and the close proximity of the hernia to bony, vascular, nerve, and urinary structures make the laparoscopic repair of suprapubic hernias (LRSPH) a formidable operation. We performed a prospective evaluation of the outcomes of patients undergoing LRSPH. METHODS: The study population comprised 36 patients undergoing LRSPH from July 1996 to January 2004. Patient demographics, hernia sizes, mesh types and sizes, perioperative outcomes, and recurrences were documented. After our early experience with this operation, the repair evolved to include transabdominal suture fixation to the pubic bone, Cooper's ligament, and above the iliopubic tract. RESULTS: There were 26 women and 10 men. They had a mean age of 55.9 years (range, 33-76) and a mean body mass index (BMI) of 31.0 kg/m2 (range, 22-67). Twenty-two (61%) of the repairs were for recurrent hernias, with an average of 2.3 previously failed open repairs each (range, 1-11). The mean hernia size was 191.4 cm2 (range, 20-768), and the average mesh size was 481.4 cm2 (range, 193-1,428). All repairs were performed with expanded polytetrafluoroethylene (ePTFE) mesh. Mean operating time was 178.7 min (range, 95-290). Mean blood loss was 40 cc (range, 20-100). One patient undergoing her fifth repair required conversion due to adhesions to a polypropylene mesh. Hospital stay averaged 2.4 days (range, 1-7). Mean follow-up was 21.1 months (range, 1-70). Complications (16.6%) included deep venous thrombosis (n = 1), prolonged pain for >6 weeks (n = 1), trocar site cellulitis (n = 1), ileus (n = 1), prolonged seroma (n = 1), and Clostridium difficile colitis (n = 1). Hernias recurred in two of our first nine patients, for an overall recurrence rate of 5.5%. Since we began using the technique of applying multiple sutures directly to the pubis and Cooper's ligament (in the subsequent 27 patients), no recurrences have been documented. CONCLUSIONS: Although technically demanding and time-consuming, the LRSPH is safe and technically feasible. Moreover, it results in a low recurrence rate and is applicable to large or multiply recurrent hernias. Transabdominal suture fixation to the bony and ligamentous structures produces a more durable hernia repair.

Gender difference in the incidence of shingles.

We investigated age- and gender-specific incidence of shingles reported in a large sentinel practice network monitoring a defined population over the years 1994-2001. In total, 5915 male and 8617 female incident cases were studied. For each age group, we calculated the relative risk of females to males presenting with shingles. Incidence rates of chickenpox and herpes simplex were examined similarly. Shingles incidence was greater in females in each age group (except for 15-24 years). Relative risks (female to male) were greatest in age groups 45-64 years (1.48) and 0-14 years (1.43). There were no gender differences in the incidence of chickenpox except in the 15-24 years age group (female excess): for herpes simplex there were female excesses in all age groups. Gender-specific age-standardized incidence rates of shingles were calculated for each year and showed a consistent female excess in each of the 8 years (average annual excess 28%).