Bundle approach in emergency surgery for prevention of surgical site infections: a double-blinded randomized controlled trial.

INTRODUCTION: Many studies have demonstrated significant antibiotic resistance by commonly isolated organisms. This is an eye-opener for the clinicians, who prescribe antibiotics day in and out. This situation shifts our attention towards the usage of antiseptic measures, which can at times play an important role in preventing and treating various infections. METHOD: This is a double-blinded randomized controlled study that compares the bundle approach to the conventional approach for the prevention of surgical site infections in patients of peritonitis undergoing midline laparotomy in emergency. The bundle approach includes three measures, namely, painting of surgical site with chlorhexidine, dabbing the wound with povidone-iodine after the closure of the rectus sheath, and application of chlorhexidine-impregnated gauze piece over the skin wound. RESULTS: The total sample size was 64 (32 in each arm). The rate of surgical site infection was significantly lower in the test arm (21.8%) as compared to the conventional arm (46.8%). The mean length of hospital stay was shorter by one day in the test arm, although, not significant. The isolates from the peritoneal fluid culture and wound culture were mostly gram-negative organisms. Most of the organisms exhibited resistance toward third generation cephalosporins, fluoroquinolones, and aminoglycosides. CONCLUSION: Antibiotic resistance is a burning concern in today's world. Alternative methods of preventing infection in the form of using antiseptics should be sought. Although our study was limited to emergency cases, this bundle approach can be implemented in elective cases as well.

Peripheral nerve blocks with liposomal bupivacaine are associated with increased opioid use compared to thoracic epidural in patients with an epigastric incision.

BACKGROUND: Thoracic epidurals are commonly recommended in enhanced recovery protocols, though they may cause hypotension and urinary retention. Peripheral nerve blocks using liposomal bupivacaine are a potential alternative, though they have not been extensively studied in major cancer operations with an epigastric incision. METHODS: We conducted a retrospective review of prospectively collected data following the transition from thoracic epidural to liposomal peripheral nerve blocks in patients undergoing major oncologic surgery. Patients receiving peripheral nerve blocks were compared to those receiving thoracic epidural. Outcome variables included postoperative opioid use (milligram morphine equivalents [MME]), severe pain, and postoperative complications. RESULTS: Forty-seven of 102 patients studied (46%) received peripheral nerve blocks. Opioid use was higher in the peripheral nerve block group during the 0-24 h (116 vs. 94 MME, p = 0.04) and 24-48 h postoperative period (94 vs. 23 MME, p < 0.01). There was no significant difference in severe pain, hypotension, urinary retention, or ileus. Peripheral nerve blocks were associated with earlier ambulation (1 vs. 2 days, p = 0.04), though other milestones were similar. CONCLUSIONS: Liposomal peripheral nerve blocks were associated with increased opioid use compared to thoracic epidural. On the basis of our results, thoracic epidural might be preferred in surgical oncology patients with an epigastric incision.

Barrier agents for adhesion prevention after gynaecological surgery.

BACKGROUND: Pelvic adhesions can form secondary to inflammation, endometriosis, or surgical trauma. Strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene, and fibrin or collagen sheets between pelvic structures. OBJECTIVES: To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth, and postoperative adhesions in women of reproductive age. SEARCH METHODS: We searched the following databases in August 2019: the Cochrane Gynaecology and Fertility (CGF) Specialised Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Epistemonikos, and trial registries. We searched reference lists of relevant papers, conference proceedings, and grey literature sources. We contacted pharmaceutical companies for information and handsearched relevant journals and conference abstracts. SELECTION CRITERIA: Randomised controlled trials (RCTs) on the use of barrier agents compared with other barrier agents, placebo, or no treatment for prevention of adhesions in women undergoing gynaecological surgery. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trials for eligibility and risk of bias and extracted data. We calculated odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) using a fixed-effect model. We assessed the overall quality of the evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods. MAIN RESULTS: We included 19 RCTs (1316 women). Seven RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (11 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (seven RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT), and mixed gynaecological surgery (one RCT). The sole indication for surgery in three of the RCTs was infertility. Thirteen RCTs reported commercial funding; the rest did not state their source of funding. No studies reported our primary outcomes of pelvic pain and live birth rate. Oxidised regenerated cellulose versus no treatment at laparoscopy or laparotomy (13 RCTs) At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose at laparoscopy reduced the incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, 3 RCTs, 360 participants; I² = 75%; very low-quality evidence) or of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, 3 RCTs, 100 participants; I² = 36%; very low-quality evidence). At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose affected the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, 1 RCT, 271 participants; very low-quality evidence). However, the incidence of re-formed adhesions may have been reduced in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, 6 RCTs, 554 participants; I² = 41%; low-quality evidence). No studies reported results on pelvic pain, live birth rate, adhesion score, or clinical pregnancy rate. Expanded polytetrafluoroethylene versus oxidised regenerated cellulose at gynaecological surgery (two RCTs) We are uncertain whether expanded polytetrafluoroethylene reduced the incidence of de novo adhesions at second-look laparoscopy (OR 0.93, 95% CI 0.26 to 3.41, 38 participants; very low-quality evidence). We are also uncertain whether expanded polytetrafluoroethylene resulted in a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants; very low-quality evidence) or a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants; very low-quality evidence) when compared with oxidised regenerated cellulose. No studies reported results regarding pelvic pain, live birth rate, or clinical pregnancy rate. Collagen membrane with polyethylene glycol and glycerol versus no treatment at gynaecological surgery (one RCT) Evidence suggests that collagen membrane with polyethylene glycol and glycerol may reduce the incidence of adhesions at second-look laparoscopy (OR 0.04, 95% CI 0.00 to 0.77, 47 participants; low-quality evidence). We are uncertain whether collagen membrane with polyethylene glycol and glycerol improved clinical pregnancy rate (OR 5.69, 95% CI 1.38 to 23.48, 39 participants; very low-quality evidence). One study reported adhesion scores but reported them as median scores rather than mean scores (median score 0.8 in the treatment group vs median score 1.2 in the control group) and therefore could not be included in the meta-analysis. The reported P value was 0.230, and no evidence suggests a difference between treatment and control groups. No studies reported results regarding pelvic pain or live birth rate. In total, 15 of the 19 RCTs included in this review reported adverse events. No events directly attributed to adhesion agents were reported. AUTHORS' CONCLUSIONS: We found no evidence on the effects of barrier agents used during pelvic surgery on pelvic pain or live birth rate in women of reproductive age because no trial reported these outcomes. It is difficult to draw credible conclusions due to lack of evidence and the low quality of included studies. Given this caveat, low-quality evidence suggests that collagen membrane with polyethylene glycol plus glycerol may be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. Low-quality evidence also shows that oxidised regenerated cellulose may reduce the incidence of re-formation of adhesions when compared with no treatment at laparotomy. It is not possible to draw conclusions on the relative effectiveness of these interventions due to lack of evidence. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. Common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.

Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery.

OBJECTIVE: To reduce the incidence of incisional hernia (IH) in colorectal surgery by implanting a mesh on the overlay position. BACKGROUND: The incidence of IH in colorectal surgery may be as high as 40%. IH causes severe health and cosmetic problems, and its repair increases health care costs. MATERIAL AND METHODS: Randomized, controlled, prospective trial. Patients undergoing any colorectal procedure (both elective and emergency) through a midline laparotomy were divided into 2 groups. The abdomen was closed with an identical technique in both groups, except for the implantation of an overlay large-pore polypropylene mesh in the study group. Patients were followed up clinically and radiologically for 24 months. RESULTS: A total of 107 patients were included: 53 in the study group and 54 in the control group. Both groups were homogeneous, except for a higher incidence of diabetes in the mesh group. There were 20 emergency procedures in the study group and 17 in the control group. There were no statistical differences in surgical site infections, seromas, or mortality between the groups (33.3%, 13.8%, and 3.7% in the control group and 18.9%, 13.2%, and 3.8% in the study group). No mesh rejection was reported. The incidence of IH was 17 of 54 (31.5%) in the control group and 6 of 53 (11.3%) in the study group (P = 0.011). CONCLUSIONS: The incidence of IH is high in patients undergoing elective or emergency surgery for colorectal diseases. The addition of a prophylactic large-pore polypropylene mesh on the overlay position decreases the incidence of IH without adding morbidity.

Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy.

INTRODUCTION: Emergent laparotomy is associated with significant wound complications including surgical site infections (SSIs) and fascial dehiscence. Triclosan-coated barbed (TCB) suture for fascial closure has been shown to reduce local complications but primarily in elective settings. We sought to evaluate the effect of TCB emergency laparotomy fascial closure on major wound complications. METHODS: Adult patients undergoing emergency laparotomy were prospectively evaluated over 1 year. Patients were grouped into TCB versus polydioxanone (PDS) for fascial closure. Subanalysis was performed on patients undergoing single-stage laparotomy. Primary outcomes were SSI and fascial dehiscence. Multivariate analysis identified independent factors associated with SSI and fascial dehiscence. RESULTS: Of the 206 laparotomies, 73 (35%) were closed with TCB, and 133 (65%) were closed with PDS. Trauma was the reason for laparotomy in 73% of cases; damage-control laparotomy was performed in 27% of cases. The overall rate of SSI and fascial dehiscence was 18% and 10%, respectively. Operative strategy was similar between groups, including damage-control laparotomy, wound vac use, skin closure, and blood products. Surgical site infection events trended lower with TCB versus PDS closure (11% vs. 21%, p = 0.07), and fascial dehiscence was significantly lower with TCB versus PDS (4% vs. 14%, p < 0.05). Subanalysis of trauma and nontrauma cases showed no difference in SSI or fascial dehiscence. Multivariable analysis found that TCB decreased the likelihood of fascial dehiscence (odds ratio, 0.07; p < 0.05) following emergency laparotomy. Increased odds of fascial dehiscence were seen in damage-control laparotomy (odds ratio, 3.1; p < 0.05). CONCLUSION: Emergency laparotomy fascial closure with TCB showed significantly decreased rates of fascial dehiscence compared with closure with PDS and a strong trend toward lower SSI events. Triclosan-coated barbed suture was independently associated with decreased fascial dehiscence rates after emergency laparotomy. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Benefits of cyanoacrylate mesh closure following exploratory laparotomy in horses.

BACKGROUND: Skin closure of laparotomy incisions using topical 2-octyl cyanoacrylate (2-OCA) mesh provides a secure bactericidal barrier in humans, which may reduce the risk of postoperative incisional complications. However, the benefits of using this mesh have not been objectively assessed in horses. METHODS: From 2009 to 2020, three methods of skin closure were used following laparotomy for acute colic, including metallic staples (MS), suture (ST) and cyanoacrylate mesh (DP). The closure method was not randomised. Owners were contacted 3 months or more after the surgery to record any postoperative complications that occurred. For each method of closure, the rates of surgical site infection (SSI) and herniation were recorded, as well as surgical time and treatment costs, including those for incisional complications. Chi-square testing and logistic regression modelling were used to assess differences between the groups. RESULTS: A total of 110 horses were recruited (45 in the DP group, 49 in the MS group and 16 in the ST group) The overall rate of SSI was 15.5%, with rates of 8.9%, 18.4% and 25% for the DP, MS and ST groups, respectively (p = 0.23). In addition, incisional hernias developed in 21.8% of cases, with 8.9%, 34.7% and 18.8% of horses in the DP, MS and ST groups, respectively, being affected (p = 0.009). The median total treatment cost did not differ significantly between groups (p = 0.47). LIMITATION: This was a retrospective study with non-randomised choice of closure method. CONCLUSIONS: No significant differences in the rate of SSI or overall cost wwere demonstrated between treatment groups. However, MS was associated with a higher rate of hernia formation than DP or ST. Despite increased capital cost, 2-OCA proved to be a safe skin closure method in horses and was no more expensive than DP or ST by the time visits to remove sutures/staples and treat infections were factored in.

Use of a modified chitosan-dextran gel to prevent peritoneal adhesions in a porcine hemicolectomy model.

BACKGROUND: The prevention of peritoneal adhesions following abdominal surgery remains an ongoing challenge, with the ideal product for adhesion reduction still elusive. This study examines the outcome of application of a modified chitosan-dextran (CD) gel within the intraperitoneal cavity of a porcine model to assess its effect on adhesion formation. This is a unique synthetic gel, its active ingredients being succinyl chitosan and dextran aldehyde. MATERIALS AND METHODS: Twenty female domestic pigs were randomized to undergo surgery alone or to receive CD gel at the time of surgery. The surgical procedures comprised of laparotomy and ileocaecal resection with ileo-colic anastomosis. At postoperative d 21, a laparoscopy was performed, and adhesions graded using a predetermined adhesion measurement score. Adhesiolysis was then performed and CD gel applied to all animals. After a further 21 d animals were euthanized and adhesions graded using the same scoring regimen. RESULTS: Adhesions involving the wound were significantly reduced following application of the gel at the time of open surgery (P = 0.01). Following adhesiolysis and further application of the gel, a decrease in adhesion scores involving the bowel was noted (P = 0.03). No significant adverse outcomes were observed with application of the gel, specifically no anastomotic leak occurred. CONCLUSIONS: Chitosan-dextran gel is a well tolerated hydrogel with beneficial properties, which has been designed in an effort to reduce postoperative peritoneal adhesion formation. The observed reduction of adhesion scores following the application of the gel is encouraging and should stimulate further development of this product. The lack of adverse outcomes following application of CD gel is reassuring when used around a bowel anastomosis.

Hyaluronate carboxymethylcellulose-based bioresorbable membrane (Seprafilm) reduces adhesion under the incision to make unplanned re-laparotomy safer.

PURPOSE: Hyaluronate carboxymethylcellulose-based bioresorbable membrane (HC membrane; Seprafilm(®)) is used to prevent postoperative adhesion. We conducted this study to assess the effectiveness of the HC membrane in reducing the severity of adhesions in patients undergoing unplanned re-laparotomy. METHODS: Between February, 2002 and December, 2010, 123 patients underwent abdominal surgery followed by a re-laparotomy in Kumamoto Regional Medical Center. The HC membrane was placed under the first abdominal incision in 60 patients (HC membrane group), whereas it was not used in the other 63 patients (control group). We compared the medical and operative records of these two groups. RESULTS: At the second laparotomy, adhesion under the incision was severe in many of the control group patients, but was significantly reduced in the HC membrane group. Postoperative small-bowel obstruction was significantly less frequent in the HC membrane group. According to univariate analysis of the risk factors for adhesion, prolonged operation time, blood loss, and not using an HC membrane were significantly associated with severe adhesion. Multivariate analysis revealed that only not using the HC membrane was significant. CONCLUSION: The HC membrane effectively reduces the severity of wound adhesion, making unplanned repeated laparotomy safer.

Rapamycin and a hyaluronic acid-carboxymethylcellulose membrane did not lead to reduced adhesion formations in a rat abdominal adhesion model.

PURPOSE: Rapamycin, an immunosuppressive in transplant surgery, has an additional antiproliferative effect. The aim of this study was to investigate the potential protective effects of rapamycin on postoperative adhesion development. METHODS: Ten rats per group underwent midline incision laparotomy and adhesion induction including bowel sutures. Therapy groups received daily intraperitoneal rapamycin injections (1.5 mg/kg body weight) for 3 weeks postoperatively. Controls were rats without any postoperative treatment, rats receiving the rapamycin solvent or a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm(™)). RESULTS: Postoperative rapamycin application led to enhanced adhesion development and there was a higher rate of wound infections. In addition, Seprafilm(™) did not reduce adhesions, in subgroups there were even more. CONCLUSIONS: Rapamycin is not recommendable for perioperative immunosuppression, it enhances adhesion development and leads to a higher rate of wound infections. Surprisingly, the established Seprafilm(™) membrane led to more adhesions in our experimental setting.

[Application of biologically active suture materials in emergency surgery of abdominal cavity organs].

An investigation of specific course of the wound process and near results of operations on 398 patients with emergency abdominal surgical pathology has revealed advantages of using new biologically active suture materials "Nikant" (with doxicyclin) and "Nikant-P" (with doxicyclin and stimulator of regeneration from the group of hermanium-containing organic compounds) in performing surgical interventions. Total number of patients with complications at the early postoperative period, operated using threads "Nikant" (38-29.9%) and "Nikant-P" (30-23.8%) proved to be reliably less than in patients of the control group (71-48.9%). The results of operations improved at the expense of considerable reduction of the number of postoperative local pyo-inflammatory processes.

Use of a bioabsorbable mesh in midline laparotomy closure to prevent incisional hernia: randomized controlled trial.

INTRODUCTION: The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention. MATERIALS AND METHODS: A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n = 167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n = 165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan. RESULTS: At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively. CONCLUSION: The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a "palliative" transient effect for preventing IH in the long-term.

An assessment of the effects of a hyaluronan-based solution on reduction of postsurgical adhesion formation in rats: a comparative study of hyaluronan-based solution and two film barriers.

BACKGROUND: Intra-abdominal application of anti-adhesive barriers may reduce the extent and severity of postoperative adhesions. This study was designed to compare the effectiveness of a sprayable liquid barrier (a mixed solution of sodium hyaluronate and carboxymethylcellulose) with two conventional sheets. METHODS: Eighty male Sprague Dawley rats underwent laparotomy with subsequent multiple intestinal wall abrasions and abdominal wall injury. Afterwards, sodium hyaluronate and carboxymethylcellulose (HA-CMC) solutions were intraperitoneally sprayed or a film barrier of either oxidized regenerated cellulose (ORC) or polylactic acid (PA) was placed under the incision. At postoperative d 21, the rats underwent relaparotomy and complete adhesiolysis. Three investigators, who were blind to the group assignment, scored the extent of adhesion formation and resected specimens for histologic examination of fibrosis and inflammation. Expression profiles of parameters as mediators (macrophages [CD68]) in cellular inflammation response were analyzed. RESULTS: Mean adhesion scores in rats that received HA-CMC solution (7.6±2.3) and ORC membrane (8.1±2.2) were lower than in rats that received PA film (10.7±2.5) and the control group (11.2±2.6) (P<0.05 for each comparison). In addition, there were significantly fewer adhesions located between large and small intestine in the HA-CMC solution group than in the control and each of the film barrier groups (P<0.05 for each comparison). CONCLUSIONS: This study suggests that both HA-CMC solution and ORC membrane decrease the overall incidence of postoperative adhesions. However, the mixed solution of HA-CMC appeared to be superior to ORC membrane because this sprayable solution is easy to use and suitable for site-specific adhesion prevention after multifocal bowel trauma.

[Indications and results of preventive endoprosthezing of the abdominal wall during operations on organs of the abdominal cavity and retroperitoneal space].

Complex examination and treatment of 120 patients with anatomo-functional insufficiency of the abdominal wall was made after operations on organs of the abdominal cavity and retroperitoneal space. In the 1st group (60 patients) the abdominal wall was sutured by traditional methods. In the 2nd group (60 patients) laparotomy was followed by implantation of polypropylene endoprosthesis by over-aponeurotic method, and suturing of the lateral wall--by sub-aponeurotic method. At the long-term postoperative period the postoperative ventral hernias were formed in 21.6% of patients of the 1st group, in the 2nd group of patients hernias were not detected. Physical component of quality of life of the 2nd group was 1.5 times, and mental component 1.7 times higher than in the 1st group.

Randomised prospective study of abdominal wall closure in patients with gynaecological cancer.

BACKGROUND: Median laparotomy is the most common approach to the abdominopelvic cavity in patients with gynaecological tumours. AIMS: The primary endpoint of the study was to evaluate the onset of incisional hernia. The secondary endpoint was to evaluate the onset of infection, wound dehiscence, wound infection, and scar pain during the post-operative period. METHODS: A total of 191 patients were eligible for the study. They were divided into three groups. Group A underwent en bloc closure of the peritoneum and fascia with Premilene suture, Group B en bloc closure of the peritoneum and fascia with Polydioxanone suture, and Group C separate closure of the peritoneum and fascia with single stitches of Ethibond suture. Statistical analysis was performed using the Statistical Software Package for Social Sciences 12.0. RESULTS: Group A and Group B comprised 63 patients, and Group C included 65 patients. The three groups proved homogeneous on statistical analysis (P > 0.05). The statistical analysis did not reveal significant differences between the different suture types and techniques with respect to the incidence of incisional hernia (P > 0.05). CONCLUSION: In our study, the incidence of incisional hernia was 8%. Randomised patients were homogeneous for sample size and risk factors. No significant differences were found between suture types or techniques. Currently, there is no suture material or technique that can be considered superior to others. When possible, we believe that the best way to prevent incisional hernia is to preserve the integrity of the abdominal wall using minimally invasive techniques.

The Effects of Fasting Status on the Relative Risk of Pulmonary Aspiration in Acute Care Surgery Patients.

BACKGROUND: Acute care surgery patients are often unfasted at the time of surgery, presenting a unique opportunity to study the effects of fasting on the risk of pulmonary aspiration. We aimed to determine the relative risk of aspiration in patients who were fasted at the time of surgery according to guidelines versus those in an unfasted state. METHODS: A retrospective chart review of 100 patients who underwent appendectomy (n = 76) or exploratory laparotomy (n = 24) was conducted at a single institution in 2016-2017. Using the American Society of Anesthesiologists (ASA) Practice Guidelines for Preoperative Fasting, patients were stratified into study and control groups according to whether they were unfasted (nothing by mouth for <8 hours prior to surgery) or fasted (nothing by mouth for >8 hours prior to surgery). Data controlled for patients' age, sex, body mass index (BMI), most recent hemoglobin A1c, presence of gastroesophageal reflux disease (GERD), and presence of hiatal hernia. RESULTS: Of the 76 patients who underwent appendectomy, 15% were unfasted with a total of 0 aspiration events (P < .001). Of the 24 patients who underwent exploratory laparotomy, 42% were unfasted with a total of 0 aspiration events (P < .001). This yields a relative risk of pulmonary aspiration of 1.0 (absolute risk of 0) in both the study and control groups. DISCUSSION: In an acute care surgery population including patients who were not fasted according to guidelines, there was no increase in the risk of pulmonary aspiration. LEVEL OF EVIDENCE: Epidemiological study; Level III.

Effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for modified Pomeroy salpingectomy: A randomized controlled trial.

OBJECTIVE: To examine the effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for postpartum modified Pomeroy partial salpingectomy. STUDY DESIGN: We enrolled 20-45-year-old women planning the procedure from March 2018 to February 2019. We randomized participants to chew simethicone 160 mg with water 50 mL 2-8 h before surgery or no treatment. The participants were not blinded; however, surgeons, care providers, and outcome assessors were blinded to the study allocation. We measured surgeon-rated operative difficulty using a 10-cm visual analog scale that represented the difficulty perceived to be resulting from bowel interference. Secondary outcomes included operative time and intraoperative and postoperative complications. RESULTS: We enrolled 60 women in each group; baseline characteristics and procedural profiles were comparable. Women in the intervention group used simethicone a median of 157 min (interquartile range 127-192) before the procedure. Surgeons rated the procedure difficulty score as 4.8 in the simethicone group and 4.5 in the control group (p = 0.57). Operative time in the two groups were 26 and 24 min, respectively (p = 0.14). We found no difference in intraoperative adverse events including blood loss and mesosalpinx tear, postoperative morbidities, hospital stay, and patient-rated satisfaction scores. CONCLUSION: Preprocedural simethicone has no demonstrable benefit in reducing operative difficulty caused by bowel interference during minilaparotomy for postpartum tubal sterilization. IMPLICATIONS: Preprocedural simethicone as given in this study did not result in reduced bowel interference and improved procedure difficulty. Further research examining simethicone in this setting would not be worthwhile as clinically meaningful benefit is unlikely.

Suturable mesh better resists early laparotomy failure in a cyclic ball-burst model.

PURPOSE: The small bites surgical technique supported by the STITCH trial has been touted as a strategy for preventing early laparotomy dehiscence through greater force distribution at the suture-tissue interface. However, this hernia prevention strategy requires an alteration in the standard closure technique that has not been widely adopted in the USA. This study seeks to determine whether incorporating a mid-weight polypropylene mesh material into a hollow-bore surgical suture material will effectively increase the force distribution at the suture-tissue interface and potentially help prevent early laparotomy dehiscence in an ex vivo model. METHODS: A cyclic stress ball-burst model was used to compare suturable mesh (0 DuraMesh™) to conventional suture. After midline laparotomy, 28 porcine abdominal wall specimens were closed with either 0 DuraMesh™ or #1 polydioxanone double-loop suture. A custom 3D-printed ball-burst test apparatus was used to fatigue the repair on a MTS Bionix Load Frame. The tissue was repetitively stressed at a physiological force of 15-120 N cycled at a rate of 0.25 Hz for a total of 1000 repetitions, followed by a load to failure, and the maximal force was recorded. RESULTS: The mean maximal force at suture pull-through was significantly higher (p < 0.0095) in the 0 DuraMesh suture group (mean: 850.1 N) compared to the 1 PDS group (mean: 714.7 N). CONCLUSION: This ex vivo study suggests that using rational suture design to improve force distribution at the suture-tissue interface may be a viable strategy for preventing the suture pull-through that drives incisional hernia.

Postoperative intra-abdominal collections using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier at the time of laparotomy for ovarian, fallopian tube, or primary peritoneal cancers.

OBJECTIVES: To determine whether HA-CMC was associated with the development of postoperative intra-abdominal collections in patients undergoing laparotomy for ovarian, fallopian tube, or primary peritoneal malignancies. METHODS: We retrospectively identified all laparotomies performed for these malignancies from March 1, 2005 to December 31, 2007. The use of HA-CMC was identified. Laparotomies for malignant bowel obstruction or repair of fistulae were excluded. Intra-abdominal collections, non-infected and infected, were defined as localized intraperitoneal fluid accumulations in the absence of re-accumulating ascites. All other complications were also captured. Appropriate statistical tests were applied using SPSS 15.0. RESULTS: We identified 219 laparotomies with HA-CMC and 204 without HA-CMC. Upper abdominal resections were performed in 65/219 (30%) HA-CMC cases compared to 39/204 (19%) cases without HA-CMC (P=0.01). The rates of large bowel and/or rectal resections were similar in both cohorts. Intra-abdominal collections were seen in 18/219 (8.2%) HA-CMC cases compared to 5/204 (2.5%) cases without HA-CMC (P=0.009). HA-CMC was independently associated with the diagnosis of a postoperative intra-abdominal collection (P=0.01). All but 2 collections developed in patients undergoing debulking procedures. CONCLUSIONS: HA-CMC appears to be associated with a higher rate of postoperative intra-abdominal collections. This seems to be greatest in patients who are undergoing a debulking procedure.

Reduction of postoperative abdominal adhesion and ileus by a bioresorbable membrane.

BACKGROUND/AIMS: This study examines the efficacy of a bioresorbable sodium hyaluronate-carboxy-methylcellulose-based membrane (HA/CMC membrane) in reducing postoperative abdominal adhesion and ileus after intestinal resection. Also, this study attempts to identify the possible factors that influence effectiveness through qualitative analysis of an individual patient case. METHODOLOGY: Bioresorable membranes were applied just prior to abdominal closure in 121 patients who underwent abdominal surgery. The incidence of adhesion-related postoperative ileus was compared between the treatment and control group. Severity and extent of adhesions were also examined in 27 patients who underwent follow-up laparotomy. RESULTS: The incidence of postoperative ileus was low in the treatment group. For the partial colectomies with lymph node dissection for colorectal cancers, there was no difference between the treatment and control group in the incidence of postoperative ileus. In patients who underwent a second operation, the incidence and severity of adhesions were significantly lower for the treated area compared with the untreated area. CONCLUSIONS: HA/CMC membrane was effective in reducing postoperative abdominal adhesions. The incidence of adhesion-related postoperative ileus after colorectal cancer surgery was unchanged. The results of qualitative analysis imply that further improvement of application may allow HA/CMC membrane to be more effective in reducing postoperative ileus.

[Incisional hernia prosthetic surgery: a prospective study comparing laparoscopic and open techniques]. / La chirurgia con protesi dei laparoceli: studio prospettico e di confronto tra le procedure laparoscopica e laparotomica.

BACKGROUND: Incisional hernia is a common complication of abdominal surgery and it is often a source of long-term morbidity. Surgical treatment include many different techniques and up to today the choice may be difficult. The employment of prosthetic materials has contributed to a remarkable improvement in the results of this surgery. We performed a prospective study to compare the outcomes after laparoscopic and open incisional hernia repair. PATIENTS AND METHODS: A total of 60 patients were assigned at random to two groups to be operated for median incisional hernia with mesh. Of these, 30 underwent laparoscopic repair and 30 open repair performed by Rives-Stoppa technique. Early and long-term outcomes were analyzed by a median follow-up of 45 months (range 31-78). Statistical analysis was done to asses differences between the groups. RESULTS: Both groups were homogeneus in terms of patient age, sex, body mass index, American Society of Anesthesiologists score and incisional hernia features. Laparoscopic repair is associated with a significantly lower incidence of wound infections, shorter operative time and hospitalization and faster return to work. The recurrence rate was similar between the two groups. CONCLUSION: In our experience laparoscopic incisional hernia repair appear to be a safe, feasible and effective alternative to Rives-Stoppa technique.