Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study).

INTRODUCTION: Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostly comprises of retrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias. METHODS: We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: 1. Creating a query. 2. Building an expert panel. 3. Executing the Delphi rounds. 4. Analysing, presenting, and reporting the Delphi results. More than 70% of agreement was defined as a consensus statement. RESULTS: The 22 experts who agreed to participate in this Delphi process for Subcostal Hernias (SCH) comprised 7 UK surgeons, 6 mainland European surgeons, 4 Indians, 3 from the USA, and 2 from Southeast Asia. This Delphi study on subcostal hernias achieved consensus on the following areas-use of mesh in elective cases; the retromuscular position with strong discouragement for onlay mesh; use of macroporous medium-weight polypropylene mesh; use of the subcostal incision over midline incision if there is no previous midline incision; TAR over ACST; defect closure where MAS is used; transverse suturing over vertical suturing for closure of circular defects; and use of peritoneal flap when necessary. CONCLUSION: This Delphi consensus defines subcostal hernias and gives insight into the consensus for incision, dissection plane, mesh placement, mesh type, and mesh fixation for these hernias.

Intraperitoneal versus extraperitoneal mesh in minimally invasive ventral hernia repair: a systematic review and meta-analysis.

PURPOSE: The ideal location for mesh placement in minimally invasive ventral hernia repair (VHR) is still up for debate. We undertook a systematic review and meta-analysis (SRMA) to evaluate the outcomes of patients who received intraperitoneal mesh versus those that received extraperitoneal mesh in minimally invasive VHR. METHODS: We searched PubMed, EMBASE, Cochrane, and Scopus from inception to May 3, 2021. We selected studies comparing intraperitoneal mesh versus extraperitoneal mesh placement in minimally invasive VHR. A meta-analysis was done for the outcomes of surgical site infection (SSI), seroma, hematoma, readmission, and recurrence. A subgroup analysis was conducted for a subset of studies comparing patients who have undergone intraperitoneal onlay mesh (IPOM) versus extended totally extraperitoneal approach (e-TEP). RESULTS: A total of 11 studies (2320 patients) were identified. We found no statistically significant difference between patients who received intraperitoneal versus extraperitoneal mesh for outcomes of SSI, seroma, hematoma, readmission, and recurrence [(RR 1.60, 95% CI 0.60-4.27), (RR 1.39, 95% CI 0.68-2.81), (RR 1.29, 95% CI 0.45-3.72), (RR 1.40, 95% CI 0.69-2.86), and (RR 1.22, 95% CI 0.22-6.63), respectively]. The subgroup analysis had findings similar to the overall analysis. CONCLUSION: Based on short-term results, extraperitoneal mesh does not appear to be superior to intraperitoneal mesh in minimally invasive ventral hernia repair. The choice of mesh location should be based on the current evidence, surgeon, and center experience as well as individualized to each patient.

Feasibility of modified-TEP technique for large inguinoscrotal and large femoral hernia and its advantages.

PURPOSE: To describe the feasibility of modified-TEP technique in reducing dead space in large inguinoscrotal and large femoral hernia to prevent seroma, reduce recurrence and complications. METHODS: This is a case series of patients who have completed a minimum of 9 months follow-up after undergoing elective endo-laparoscopic inguinal hernia repair with modified-TEP technique for large inguinoscrotal and large femoral hernia in a single institution from June to October 2020. RESULTS: 14 large inguinoscrotal hernia and 4 large femoral hernia were repaired using the modified-TEP technique in 15 patients. These patients reported minimal pain after surgery. There were no reported seroma, complications or recurrences up to 9 months follow-up period. CONCLUSION: Modified-TEP technique for large inguinoscrotal and large femoral hernia has shown good outcomes and patients reported minimum levels of pain. In experienced hands, it is safe, feasible and effective in reducing seroma formation and hernia recurrence.

Minimally invasive repair for lateral ventral hernia: tailored approach from a hernia centre at a tertiary care institution.

INTRODUCTION: Lateral ventral hernia (LVH) is rare and can be primary or secondary. Surgical treatment of this rare hernia type is challenging due the anatomic location and technical challenges in placement and secure anchoring of mesh. METHOD: Patient demographic data, intra-operative data and post-operative outcomes on all LVH repairs performed with endo-laparoscopic and robotic approach between 2016 to 2018 were reviewed and analysed. RESULTS: 22 LVH were repaired in 21 patients. 9 had primary hernia and 13 had secondary hernia. All patients underwent minimally invasive surgery (MIS) for hernia repair with no conversion to open surgery. Fascial defect closure and placement of mesh were performed in all cases. Different approaches were utilized: 9 hernia repaired with laparoscopic intra-peritoneal on-lay mesh technique with defect closure (IPOM +), 4 had laparoscopic trans-abdominal pre-peritoneal repair (TAPP), another 4 had extended totally extra-peritoneal repair (eTEP), 3 had robotic TAPP (rTAPP) and 2 repaired with trans-abdominal partial extra-peritoneal (TAPE) approach. 4 (19%) of the patients developed post-operative seroma which were managed conservatively. No other significant complication was noted, and no chronic pain or recurrence reported within a minimum follow-up of 12 months. CONCLUSION: This case series gives a broad outline of possible MIS options available for LVH repair and recommendations for a tailored approach. The surgical technique needs to be individualized according to the size and anatomic location of the defect, other intra-operative findings and patient characteristics.

Effect of direct defect closure during laparoscopic inguinal hernia repair ("TEP/TAPP plus" technique) on post-operative outcomes.

PURPOSE: Seroma formation and recurrence in large inguinal hernia still remain an important clinical complication despite decades since the advent of mesh repair. METHODS: In our prospective comparative analysis, we want to evaluate the effect of direct hernia defect closure on surgical outcomes in patients undergoing laparoscopic inguinal hernia repair in two tertiary care institutions in Singapore. The direct hernia defects were closed with non-absorbable sutures incorporating the pseudosac. RESULTS: A group of 241 patients underwent laparoscopic inguinal hernia mesh repair for a total of 378 direct defects from April 2014 to July 2018. Of these patients, 98 (40.6%) patients underwent hernia repair without closure of their direct defect while 143 (59.4%) patients underwent direct defect closure. No significant differences were observed between the two patient populations' demographic information and the mean operative time. A total of 219 direct defects were closed and 159 direct defects were not repaired. Compared to the group that did not undergo direct defect closure, the group that had closure of the direct defects demonstrated a statistically significant reduction in recurrence (4.4% versus 0.9%, p = 0.036) and seroma formation (12.6% versus 6.4%, p = 0.045). CONCLUSION: Direct defect closure has proven to be effective in reducing recurrence and seroma formation post-operatively in patients undergoing laparoscopic inguinal hernia repair. Randomized controlled trials will be required to further evaluate these outcomes.

Ipsilateral nonrecurrent laryngeal nerve palsy and delayed palsy of the contralateral recurrent laryngeal nerve in a case of third-time reoperative thyroid surgery.

The occurrence of nonrecurrent laryngeal nerve and delayed nerve palsy of the contralateral nerve occurring simultaneously has never been described. A 67-year-old woman underwent reoperative completion thyroidectomy for enlarging thyroid nodules with recurrent hyperthyroidism and obstructive symptoms. Preoperative computed tomography of the neck showed a large compressive goitre with an aberrant right subclavian artery. At surgery, a type 1 nonrecurrent laryngeal nerve was found and inadvertently transected due to dense adhesions. It was repaired with ansa cervicalis graft. A fully preserved and functional recurrent laryngeal nerve was seen on the contralateral side at the end of surgery. However, the patient developed a delayed palsy on day 4 of the recurrent laryngeal nerve requiring a tracheostomy. Following successful speech and swallowing therapy, the patient was decannulated with good phonation and recovery of the left cord. Patients are at risk of bilateral nerve injury and late onset palsy in reoperative thyroid surgery. Management can be challenging and should be recognised to ensure appropriate therapy.

Methicillin resistant Staphylococcus aureus contamination of phlebotomy tourniquets and faucets

Introduction: Methicillin resistant Staphylococcus aureus (MRSA) is transmitted through direct contact or fomites. The most important means of nosocomial spread is by hospital personnel. However, fomites are being increasingly recognized as sources of nosocomial infection. Objectives: Our aim was to describe the MRSA contamination rate of phlebotomy tourniquets and faucets in a tertiary care hospital and to compare the contamination of plastic tourniquets with that of fabric tourniquets. Method: A cross-sectional study was carried out in the general wards of a tertiary care hospital in the Colombo District. Two hundred tourniquets were collected and 100 faucets were swabbed and cultured on CHROMagar™ MRSA medium (CHROMagar Microbiology). Contamination rates of 50 plastic tourniquets and 50 fabric tourniquets were compared. Results: MRSA grew in 26% of tourniquets. Majority were plastic tubes. MRSA contamination of tourniquets did not significantly differ by ward (p>0.4). MRSA was found on 26% of faucets. Contamination rate was highest in the common wards for dermatology, dental, rheumatology, and neurology (55.6%), followed by gynaecology (45.2%), cardiology (33.3%), surgery (18.8%), psychiatry (11.1%), and medicine (5.6%). There was a significant difference in rates of contamination of faucets in the different wards (p<0.01). There was no significant difference in the colony count per surface area of the two types of tourniquets after a single use. Conclusions: MRSA contamination rates of tourniquets and faucets were high. Single-use plastic tourniquets were much less contaminated with MRSA than reused tourniquets.

Psychological distress among students from five universities in Sri Lanka.

OBJECTIVE: To determine the proportion of university students that are psychologically distressed when compared to an age and sex matched population sample and to describe the factors that may contribute to their distress. DESIGN: A cross-sectional comparison study. METHODS: The general health questionnaire (GHQ 30), previously validated in Sinhala, was administered as a screening test to random samples of undergraduates in 5 universities. Age and sex matched controls from the respective communities were also administered the screening test. The undergraduates also filled in a pre-tested questionnaire with personal details. Chi-square tests were used to determine statistical significance between groups. RESULTS: Among the undergraduates, 104 (39.8%) had scores for psychological distress whereas only 67 (25.7%) from the community sample had scores for similar distress. This difference was significant (p = 0.0007). A significantly greater proportion (p = 0.009) of those entering from rural schools were psychologically distressed than those from suburban and urban schools, and a greater proportion living in rented rooms and hostels were (p = 0.001) distressed than those travelling from their homes. CONCLUSIONS: The psychological distress among undergraduates was significantly greater than among the general population. More students who enter from rural schools seem to be distressed than those who enter from suburban and urban schools.