MIS retromuscular repair of lateral incisional hernia: technological deliberations and short-term outcome.

BACKGROUND: Lateral abdominal wall hernias (LAWH) constitute about 1-4% of hernia surgical procedures. They represent a unique surgical challenge on account of their potential for anatomical complexity and consequent operative technical demand. Furthermore, LAWH repairs are currently not standardized, and remain contentious, despite a variety of approaches. These repairs are attendant with not insignificant morbidity and recurrence rates. We profile here our endoscopic and hybrid surgical approach to the management of LAWH and early therapeutic outcomes. METHODS: A retrospective review of our hernia clinical database between March 2018 and December 2020 was performed to extract all LAWH (with and without an associated midline component) patients, who underwent an enhanced-view totally extra peritoneal (eTEP) hernia repair with a transversus abdominis release (TAR), or a hybrid repair. Initial outcome data (6-month follow-up) is profiled here. The primary outcome measures were hernia recurrence and hernia-site bulging. The secondary measures were surgical site occurrence (SSO) and hernia-related quality of life (QoL). RESULTS: A total of 33 LAWH patients underwent an eTEP TAR or hybrid hernia repair. 11 patients had an associated midline defect and 12 were recurrent hernias. The mean hernia defect area was 84.2 ± 49 cm2 and mean mesh size was 859.6 ± 263 cm2. There was no hernia recurrence at initial follow-up of 24 months. The SSO rate was 12%. The CCS QoL scores were 34.6 ± 2 pre-operatively, and improved to 27.2 ± 4 at 6 months. CONCLUSIONS: Our endoscopic and hybrid technique is a safe, reproducible, and technically promising approach for the repair of LAWH. Thorough knowledge of the surgical anatomy of the lateral abdominal wall and advanced endosurgical skills are imperative for good outcomes. We await the long-term results of our LAWH cohort to confirm the findings.

Are drains useful in eTEP ventral hernia repairs? An AWR surgical collaborative (AWRSC) retrospective study.

BACKGROUND: Drain practices in minimally invasive retromuscular ventral hernia repairs have largely been transferred over from open surgery without significant review. We wished to evaluate the role of drains in these repairs. METHODS: Using the Abdominal Wall Reconstruction Surgical Collaborative (AWRSC) registry, patients with ventral hernias who underwent enhanced-view totally extraperitoneal (eTEP) repairs between February 2016 and September 2019 were evaluated. Patients with contamination or active infection within the surgical field, those who underwent an emergent or hybrid repair, or received a concomitant procedure were excluded. Propensity score matching based on the defect size, previous hernia repair status, and the use of posterior component separation (PCS) was used to match patients with drains to patients without drains. We evaluated 180-day outcomes in terms of SSIs, SSOs, and recurrence. RESULTS: 308 patients met the inclusion criteria. After propensity score matching, 48 patients with drains and 72 without drains were included in the analysis cohort. Those with drains were older with a greater likelihood of an incisional hernia, but were broadly similar for other relevant demographic and hernia-related variables. While there was no difference in the incidence of SSOs and SSIs between the two groups, we report a higher risk of SSOs needing procedural intervention (SSOPI) and recurrence, with a lengthened hospital stay in the cohort that received surgical drains. CONCLUSION: The use of surgical drains in "clean" eTEP repairs of ventral hernias appears to be common, with a selection bias for more complex cases. Based on our analysis, we found the use of drains was associated with longer hospital stays. The use of drains did not change the likelihood of suffering an SSI or SSO. However, the incidence of SSOPIs was higher despite the use of drains, which raises questions about their protective role in these repairs.

A Detailed History of Retromuscular Repairs for Ventral Hernias: A Story of Surgical Innovation.

BACKGROUND: We performed a historical review of events concerning retromuscular hernia repairs over the last two centuries. This may shed light on surgical innovators and their novel techniques that have evolved into current practices. METHODS: Literature reviews of notable surgeons in the subspecialty were reviewed. Historical context was obtained by personal communication with contemporary surgeons who witnessed changes in established techniques firsthand. RESULTS: Even though retromuscular repairs are the central theme of this exercise, it is important to note several adjacent events which steered surgical progress. The status of hernia surgery today is the result of the work of several pioneers separated by time and distance. CONCLUSIONS: It may be important to understand the circumstances that have propelled past surgical breakthroughs to stimulate future progress.

e-TEP repair for midline primary and incisional hernia: technical considerations and initial experience.

INTRODUCTION: The Enhanced-View Totally Extra Peritoneal Rives-Stoppa (e-TEP-RS) Technique for the repair of large, complex, ventral abdominal hernias has gained popularity especially in overcoming the disadvantages with Intra Peritoneal Onlay Mesh (IPOM) repairs and to enable siting of a large prosthetic mesh in an anatomical plane distinct from the abdominal cavity and its contents. Evolving variations of the original technique have allowed the definitive repair of such defects in a reproducible manner. We present our initial experience of this approach and detailed steps of our native technical modifications in overcoming the challenges in performing this complex and potentially challenging procedure. MATERIALS AND METHODS: This is a retrospective review of the clinical data of midline, large, complex, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR). Patients, with or without Diastasis of Rectus Abdominis Muscle (DRAM) were included. Key outcomes measured were post-operative pain, operative morbidity, readmission, Quality of Life (QoL), hernia recurrence. RESULTS: A total of 58 midline, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR), between March 2018 and December 2019 were studied. Mean defect area was 41.0 ± 28 cm2 and the mean mesh surface area was 473.5 ± 165 cm2. e-TEP-RS was done in 35 cases, e-TEP RS TAR in 15 cases and e-TEP-RS with e-TEP inguinal in 08 cases. There was no intraoperative morbidity. Mean duration of surgery was 156.2 ± 40 min and mean blood loss was 40.5 ± 26 cc. The CCS QoL scores improved from 34.6 (± 2) pre-operatively to 27.2 (± 4) at the end of 6 months. One patient had a supra-umbilical recurrence following bilateral TAR over the superior edge of the mesh. Follow-up ranged from 6 to 22 months, with a mean of 14 months. Major complications (n = 12; 20.7%) were seroma formation and prolonged ileus. CONCLUSION: The e-TEP-RS technique for large, complex, midline, ventral abdominal hernias can be used with excellent results and acceptable morbidity. This technique is technically challenging and should be mastered in relatively smaller ventral hernias to achieve good results before attempting it in larger, complex ones.

Signs and landmarks in eTEP Rives-Stoppa repair of ventral hernias.

BACKGROUND: After years of playing second-fiddle to laparoscopic underlay repairs, the retro-muscular Rives-Stoppa repair is rapidly gaining popularity thanks to the endoscopic eTEP approach. It extends all the advantages of a retro-muscular mesh placement-increased tolerance for infection, mechanical robustness, reduced need for mesh fixation-in an ergonomically acceptable system. METHODS: The eTEP technique described by Belyansky's group requires a "crossover" from one retro-rectus space to the other. The aim of the crossover is to safely amalgamate the retro-rectus spaces for placement of a large extra-peritoneal prosthesis. By salvaging peritoneum in the midline and operating in the extra-peritoneal plane, one can avoid large defects in the posterior rectus sheath (PRS)-peritoneum complex which need closure. Correct identification of anatomical landmarks is imperative to safely perform the surgery. RESULTS: The "lamppost sign" signals the lateral limit of retro-rectus dissection, preventing iatrogenic injury to the neurovascular bundles and linea semilunaris. After crossover has been safely achieved, the medial edges of the divided posterior rectus sheaths are found connected to each other by a strip of pre-peritoneal fat and peritoneum in the midline. These structures, along with the neck of hernia constitute the "volcano sign". For inferior defects, the vas deferens, the inferior epigastric and gonadal vessels form a triradiate conformation termed the "Mercedes-Benz sign". CONCLUSION: These signs serve as tools to identify the composition of the surgical field, avoiding iatrogenic injury to the linea alba and linea semilunaris, while reducing the time taken for posterior closure.

Acronyms Use in Abdominal Wall Reconstruction: Introduction to a New Language.

BACKGROUND: The use of acronyms in medicine is widespread, aiming to simplify and condense communication. Online communication in social media platforms seems to enhance the use of acronyms, but their efficiency in message delivery may be negated by their abundance and unfamiliarity, causing more confusion than clarity. We analyzed the use of acronyms in a closed Facebook group dedicated to abdominal wall reconstruction (AWR), as the rapid recent development of this field has resulted in many new acronyms. Our aim was to classify the different acronyms and create a public reference. METHODS: The International Hernia Collaboration, a hernia-related Facebook group, now communicating more than 7500 surgeons from 99 countries, was studied, by extracting acronyms used since its inception in 2012. Acronyms were categorized and interpreted, to create a small dictionary comprised of several tables. RESULTS: Commonly used acronyms were identified, as well as commonly used prefixes that modify the acronyms' meaning. Tables were created, classifying acronyms by their subject: 1.Anatomy2.Diseases and clinical conditions3.Techniques and materials. CONCLUSION: The use of acronyms increased in social media-based communication. Aiming to simplify the language, the inflation of terms may have achieved the opposite, by adding a multitude of unfamiliar and confusing terms. We have created a public reference for AWR-related acronyms. Limiting the liberal creation of new acronyms is recommended, especially in a rapidly changing field as AWR.

Schizophrenia and bipolar disorders: The Toxoplasma connection.

The infectious etiology of psychiatric illnesses has remained an unexplored area till recently. During the past two decades, numerous studies from multiple angles have tried to link chronic toxoplasmosis with schizophrenia and bipolar disorders, among others. Most of the evidence has come from serological studies in the patient population, but other facets have also been explored. This review examines the various areas from which a causal link has been deduced and includes: (a) serological studies, (b) effect of maternal toxoplasmosis on children, (c) neurotransmitter studies, (d) parasite localization in the brain, (e) role of cytokines, and (f) psychotherapy and its effect on Toxoplasma. However, multiple factors may play a role in the etiopathogenesis of psychiatric illnesses, and chronic Toxoplasma infection may be considered an important risk factor for the genesis and symptomatology of schizophrenia and bipolar disorders.

Seroprevalance of rubella in women with bad obstetric history.

Rubella is a common cause of rash and fever during childhood. However, its public health importance relates to the teratogenic effects of primary rubella infection occurring in pregnant women, which can lead to fetal death with spontaneous abortion or to congenital defects in surviving infants. Most of the cases are asymptomatic and difficult to diagnose on clinical grounds. Detection of specific IgM antibodies by the enzyme-linked immunosorbent assay (ELISA) technique is a useful method for diagnosis. The present study was conducted on 180 pregnant women attending antenatal clinics at Government Maternity Hospital, Tirupati. All the serum samples were tested for Rubella-specific IgM antibodies. A seropositivity of 12.67% was observed among cases with bad obstetric history and 6.67% in normal pregnant women. Within the test group, high sero-positivity (13.33%) was observed in women with repeated abortions followed by in cases of intrauterine death (12.73%). The results indicate high prevalence of rubella in our population. All antenatal cases should be routinely screened for rubella, so that early diagnosis will help in proper management and fetal outcome.

Isolation, speciation, and antibiogram of clinically relevant non-diphtherial Corynebacteria (Diphtheroids).

PURPOSE: Coryneform or the non-diphtherial Corynebacterium species largely remains a neglected group with the traditional consideration of these organisms as contaminants. This concept, however, is slowly changing in the light of recent observations. This study has been done to find out the species distribution and antibiogram of various members of the clinically relevant Coryneform group, isolated from various clinical materials. MATERIALS AND METHODS: One hundred and fourteen non-duplicate isolates of diphtheroids from various clinical isolates were selected for the study. The isolates were identified to the species level by using a battery of tests; and antimicrobial susceptibility was tested by using a combination of Clinical and Laboratory Standards Institute (CLSI) and the British Society for Antimicrobial Chemotherapy (BSAC) guidelines, in the absence of definitive CLSI guidelines. RESULTS: Corynebacterium amycolatum was the predominant species (35.9%) in our series followed by the CDC Group G organisms (15.7%). Each of the remaining 19 species comprised of less than 10% of the isolates. More than half the total isolates were resistant to the penicillins, erythromycin, and clindamycin; while excellent activity (all the strains being susceptible) was shown by vancomycin, linezolid, and tigecycline. Chloramphenicol and tetracycline also had good activity in inhibiting more than 80% of the isolates. Multiply drug resistance was exhibited by all the species. CONCLUSION: This study was an attempt to establish the clinical significance of coryneform organisms. The high level of resistance shown by this group to some of the common antibacterial agents highlights the importance of processing these isolates in select conditions to guide the clinicians towards an appropriate therapy.