Perioperative Telemedicine Utilization Among Geriatric Patients Being Evaluated for Abdominal Wall Reconstruction and Hernia Repair.

Introduction: Perioperative telemedicine services have increasingly been utilized for ambulatory care, although concerns exist regarding the feasibility of virtual consultations for older patients. We sought to review telemedicine encounters for geriatric patients evaluated at a hernia repair and abdominal wall reconstruction center. Methods: A retrospective review of telemedicine encounters between May 2020 and May 2021 was performed. Patient characteristics and encounter-specific outcomes were compared among geriatric (older than65 years old) and nongeriatric patients. Clinical care plans for encounters were reviewed to determine potential downstream care utilization. Patient-derived benefits related to time saved in travel time was calculated using geo-mapping. Outcomes for postoperative encounters were assessed to determine if complication rates differed between geriatric and nongeriatric populations. Results: A total of 313 telemedicine encounters (geriatric: 41.9%) were conducted among 251 patients. Reviewing preoperative factors for hernia care, geriatric patients presented with higher rates of recurrent or incisional hernias (87.9% vs. 70.7%, p < 0.01). Potential travel time was longer for geriatric patients (104 min vs. 42 min, p = 0.03) in the preoperative setting. No differences in clinical care plans were found. Only 8.6% of preoperative encounters resulted in recommendations for supplemental in-person evaluation. Operative plans were coordinated for 42.5% of all preoperative telemedicine encounters. There was no difference in complication rate between geriatric and nongeriatric patients (p > 0.05) in the postoperative setting, with no complications directly attributable to telemedicine-based care. Conclusions: Telemedicine-based evaluations appear to function well among geriatric patients seeking hernia repair and abdominal wall reconstruction. Clinical care plans rendered following telemedicine-based encounters are appropriate with a low rate of supplemental in-person evaluations. Telemedicine use resulted in significantly more time saved in commuting to and from clinic for geriatric patients.

Outcomes of Telemedicine-Based Consultation among Rural Patients Referred for Abdominal Wall Reconstruction and Hernia Repair.

BACKGROUND: Perioperative telemedicine use has increased as a result of the COVID-19 pandemic and may improve access to surgical care. However, studies assessing outcomes in populations at risk for digital-health disparities are lacking. We sought to characterize the pre- and postoperative outcomes for rural patient populations being assessed for hernia repair and abdominal wall reconstruction with telehealth. METHODS: Patients undergoing telehealth evaluation from March 2020 through May 2021 were identified. Rurality was identified by zip code of residence. Rural and urban patients were compared based on demographics, diagnosis, treatment plan, and visit characteristics and outcomes. Downstream care use related to supplementary in-person referral, and diagnostic testing was assessed. RESULTS: Three hundred-seventy-three (196 preoperative, 177 postoperative) telehealth encounters occurred during the study period (rural: 28% of all encounters). Rural patients were more likely to present with recurrent or incisional hernias (90.0 vs 72.7%, p = 0.02) and advanced comorbidities (American Society of Anesthesiologists status score > 2: 73.1 vs 52.1%, p = 0.009). Rural patients derived significant benefits related to time saved commuting, with median distances of 299 and 293 km for pre- and postoperative encounters, respectively. Downstream care use was 6.1% (N = 23) for additional in-person evaluations and 3.4% (N = 13) for further diagnostic testing, with no difference by rurality. CONCLUSIONS: Perioperative telehealth can safely be implemented for rural populations seeking hernia repair and may be an effective method for reducing disparities. Downstream care use related to additional in-person referral or diagnostic testing was minimally impacted in both the preoperative and postoperative settings. These findings suggest that rurality should not deter surgeons from providing telemedicine-based surgical consultation for hernia repair.

Outcomes for audio-only and video-based preoperative encounters for abdominal wall reconstruction and hernia consultations.

BACKGROUND: Digital health is commonly utilized for surgical evaluation, however little is known regarding the relative effectiveness of audio-only and video-based encounters. METHODS: A retrospective analysis of all patients undergoing preoperative digital health encounters at a hernia center from March 2020-May 2021 was conducted. Visit types were dichotomized to audio-only and video-based encounters. Downstream care utilization and visit-specific outcomes were analyzed. RESULTS: 204 preoperative digital health encounters were conducted during the study period. Audio-only encounters were more commonly performed for patients classified as older and rural. Supplemental in-person examinations were required among 13.5% and 4.0% of new- and established-patient encounters, respectively, with no significant difference between audio-only and video-based assessments. Finalized operative plans were coordinated for 43.6% of patients, with no significant difference among groups. CONCLUSIONS: Patients being evaluated with audio-only encounters are more likely to be older and reside in rural settings, yet demonstrate no significant difference in downstream care utilization and clinic encounter outcomes relative to those being evaluated via video-based assessment. Enabling audio-only surgical consultations may minimize disparities in digital care.

A National Evaluation of Surgeon Experiences in Telemedicine for the Care of Hernia and Abdominal Core Health Patients.

BACKGROUND: Surgeons are increasingly utilizing telemedicine to provide perioperative services to patients. Safety, satisfaction, and feasibility of these programs in general populations have been established, but it is unclear how telemedicine can be integrated into subspecialty care. We report results of a national survey related to telehealth practices among members of the Abdominal Core Health Quality Collaborative (ACHQC). METHODS: Survey responses were analyzed to determine current strategies in telemedicine utilization. Surgeon preferences, perceptions of validity, and identified barriers to implementation of telemedicine were assessed. RESULTS: Forty surgeons within the ACHQC responded, with 90% of respondents reporting use of telemedicine to deliver perioperative care to patients with hernias and abdominal core health concerns. Surgeons appeared to be more comfortable managing preoperative patients with image-confirmed diagnoses of hernias. Surgeons were universally more comfortable delivering postoperative care via telemedicine. Connectivity, patient engagement, and reimbursement were identified as potential barriers to expansion of telemedicine. Seventy-eight percent of respondents reported that they would increase telemedicine utilization if current regulations were maintained in the future. CONCLUSIONS: This study found that hernia specialists are utilizing telemedicine at a higher rate than before the COVID-19 pandemic, with surgeons reporting interest in continued use of this modality beyond the pandemic. These findings suggest that future work in telemedicine optimization may improve the quality of care that can be delivered to patients with abdominal core health concerns.

Current Surgical Trainee Perceptions and Experiences in Telehealth.

Introduction:Broad expansion of telehealth technologies has been implemented during the coronavirus disease 2019 (COVID-19) pandemic to allow for physical distancing and limitation of viral transmission within health care facilities. Although telehealth has been studied for its impact on patients, payors, and practitioners, its educational impact is largely unstudied. To better understand the trainee experience and perception of telehealth during the COVID-19 pandemic, we conducted a survey of the membership of the American College of Surgeons Resident and Associate Society (RAS).Methods:An anonymous survey was sent to members of RAS. Descriptive analysis was used to report experiences and perceptions. Chi-square analysis was used to compare cohorts with and without exposure to telehealth.Results:Of the 465 RAS respondents, 292 (62.8%) reported knowledge of telehealth technologies at their institutions. The majority of these respondents experienced a decrease in in-person clinic volume (94.4%) and an associated increase in virtual clinic volume (95.7%) related to the COVID-19 pandemic. Trainee integration into telehealth workflows increased drastically from prepandemic levels (11% vs. 54.5%, p < 0.001). Likelihood of trainee exposure to telehealth was associated with university-based training programs or larger program size. Trainees demonstrated a desire for more integration and development of curricula.Conclusions:These data serve as the first description of surgical trainee experience with, and opinion of, telehealth. Trainees recognize the importance of their integration and training in telehealth. These results should be used to guide the development of workflows and curricula that integrate trainees into telemedicine clinics.

Current practices in complex abdominal wall reconstruction in the Americas: need for national guidelines?

BACKGROUND: Component separation (CS) procedures have become an important part of surgeons' armamentarium. However, the exact criteria for training, procedure/mesh choice, as well as patient selection for CS remains undefined. Herein we aimed to identify trends in CS utilization between various cohorts of practicing surgeons. STUDY DESIGN: Members of the Americas Hernia Society were queried using an online survey. Responders were stratified according to their experience, practice profile (private vs academic, general vs hernia surgery), and volume (low (< 10/year) vs high) of CS procedures. We used Chi-squared tests to evaluate significant associations between surgeon characteristics and outcomes. RESULTS: 275 responses with overwhelming male preponderance (88%) were collected. The two most common self-identifiers were "general" (66%) and "hernia" (28%) surgeon. PCS was the most commonly (67%) used type of CS; endoscopic ACS was least common (3%). Low-volume surgeons were more likely to utilize the ACS (p < 0.05). Only 7% of respondents learned PCS during their residency, as compared to 36% that use ACS. 65% felt 0-10 cases was sufficient to become proficient in their preferred technique. 10 cm-wide defect was the most common indication for CS; 23% used it for 5-8 cm defects. Self-identified "hernia" and high-volume surgeons were more likely to use synthetic mesh in the setting of previous wound infections and/or contaminated field (p < 0.05). More general/low-volume surgeons use biologic mesh. Contraindications to elective CS varied widely in the cohort, and 9.5% would repair poorly optimized patients electively. Severe morbid obesity was the most feared comorbidity to preclude CS. CONCLUSION: The use of CS varies widely between surgeons. In this cohort, we discovered that PCS was the most commonly used technique, especially by hernia/high-volume surgeons. There are differences in mesh utilization between high-volume and low-volume surgeons, specifically in contaminated fields. Despite its prevalence, CS training, indications/contraindications, and patient selection must be better defined.

Local insulin application has a dose-dependent effect on lumbar fusion in a rabbit model.

The purpose of this study was to determine if locally applied insulin has a dose-responsive effect on posterolateral lumbar fusion. Adult male New Zealand White rabbits underwent posterolateral intertransverse spinal fusions (PLFs) at L5-L6 using suboptimal amounts of autograft. Fusion sites were treated with collagen sponge soaked in saline (control, n = 11), or with insulin at low (5 or 10 units, n = 13), mid (20 units, n = 11), and high (40 units, n = 11) doses. Rabbits were euthanized at 6 weeks. The L5-L6 spine segment underwent manual palpation and radiographic evaluation performed by two fellowship trained spine surgeons blinded to treatment. Differences between groups were evaluated by analysis of variance on ranks followed by post-hoc Dunn's tests. Forty-three rabbits were euthanized at the planned 6 weeks endpoint, while three died or were euthanized prior to the endpoint. Radiographic evaluation found bilateral solid fusion in 10%, 31%, 60%, and 60% of the rabbits from the control and low, mid, and high-dose insulin-treated groups, respectively (p < 0.05). As per manual palpation, 7 of 10 rabbits in the mid-dose insulin group were fused as compared to 1 of 10 rabbits in the control group (p < 0.05). This study demonstrates that insulin enhanced the effectiveness of autograft to increase fusion success in the rabbit PLF model. The study indicates that insulin or insulin-mimetic compounds can be used to promote bone regeneration.

Asymptomatic Congenital Lung Malformations: Timing of Resection Does Not Affect Adverse Surgical Outcomes.

Background: Optimal timing for resection of asymptomatic congenital lung malformations (CLMs) remains controversial. The aim of this study is to define optimal timing for surgical intervention of patients with CLMs and define clinical variables that affect surgical outcomes. Methods: An IRB-approved retrospective analysis was conducted for patients undergoing surgery for CLMs between 2012 and 2017. Subjects were divided into cohorts based on timing of operative intervention. "Early intervention" was defined as surgery within 4 months of birth; "intermediate intervention"-between 4 and 6 months; and "late intervention"-6-12 months. Surgical outcomes including intraoperative estimated blood loss (EBL), surgical time, post-operative pneumothorax, length of time chest tube stayed in, and hospital length of stay were compared among the three groups using Fisher's exact test or Chi-squared test for categorical variables and one-way analysis of variance test for continuous variables. Results: We analyzed 63 patients who underwent surgery for CLM. There were no significant differences in baseline characteristics. Timing of surgery did not significantly correlate with post-operative outcomes. Specifically, there was no difference in operative time, EBL, post-operative pneumothorax, or length of hospital stay among the early, intermediate, and late intervention groups. Even after controlling for cyst-volume ratio (CVR), timing of surgery still did not affect post-operative outcomes. Conclusions: Surgical outcomes for resection of CLMs are not significantly affected by timing of surgery. We advocate for early intervention to decrease the incidence of associated complications that can occur with later intervention.