Towards a Standardization of Learning Curve Assessment in Minimally Invasive Liver Surgery.

OBJECTIVE: The aim was to analyze the learning curves of minimal invasive liver surgery(MILS) and propose a standardized reporting. SUMMARY BACKGROUND DATA: MILS offers benefits compared to open resections. For a safe introduction along the learning curve, formal training is recommended. However, definitions of learning curves and methods to assess it lack standardization. METHODS: A systematic review of PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in MILS. The primary outcome was the number needed to overcome the learning curve. Secondary outcomes included endpoints defining learning curves, and characterization of different learning phases(competency, proficiency and mastery). RESULTS: 60 articles with 12'241 patients and 102 learning curve analyses were included. The laparoscopic and robotic approach was evaluated in 71 and 18 analyses and both approaches combined in 13 analyses. Sixty-one analyses (60%) based the learning curve on statistical calculations. The most often used parameters to define learning curves were operative time (n=64), blood loss (n=54), conversion (n=42) and postoperative complications (n=38). Overall competency, proficiency and mastery were reached after 34 (IQR 19-56), 50 (IQR 24-74), 58 (IQR 24-100) procedures respectively. Intraoperative parameters improved earlier (operative time: competency to proficiency to mastery: -13%, 2%; blood loss: competency to proficiency to mastery: -33%, 0%; conversion rate (competency to proficiency to mastery; -21%, -29%), whereas postoperative complications improved later (competency to proficiency to mastery: -25%, -41%). CONCLUSIONS: This review summarizes the highest evidence on learning curves in MILS taking into account different definitions and confounding factors. A standardized three-phase reporting of learning phases (competency, proficiency, mastery) is proposed and should be followed.

Technical skill assessment in minimally invasive surgery using artificial intelligence: a systematic review.

BACKGROUND: Technical skill assessment in surgery relies on expert opinion. Therefore, it is time-consuming, costly, and often lacks objectivity. Analysis of intraoperative data by artificial intelligence (AI) has the potential for automated technical skill assessment. The aim of this systematic review was to analyze the performance, external validity, and generalizability of AI models for technical skill assessment in minimally invasive surgery. METHODS: A systematic search of Medline, Embase, Web of Science, and IEEE Xplore was performed to identify original articles reporting the use of AI in the assessment of technical skill in minimally invasive surgery. Risk of bias (RoB) and quality of the included studies were analyzed according to Quality Assessment of Diagnostic Accuracy Studies criteria and the modified Joanna Briggs Institute checklists, respectively. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: In total, 1958 articles were identified, 50 articles met eligibility criteria and were analyzed. Motion data extracted from surgical videos (n = 25) or kinematic data from robotic systems or sensors (n = 22) were the most frequent input data for AI. Most studies used deep learning (n = 34) and predicted technical skills using an ordinal assessment scale (n = 36) with good accuracies in simulated settings. However, all proposed models were in development stage, only 4 studies were externally validated and 8 showed a low RoB. CONCLUSION: AI showed good performance in technical skill assessment in minimally invasive surgery. However, models often lacked external validity and generalizability. Therefore, models should be benchmarked using predefined performance metrics and tested in clinical implementation studies.

Proposal and multicentric validation of a laparoscopic Roux-en-Y gastric bypass surgery ontology.

BACKGROUND: Phase and step annotation in surgical videos is a prerequisite for surgical scene understanding and for downstream tasks like intraoperative feedback or assistance. However, most ontologies are applied on small monocentric datasets and lack external validation. To overcome these limitations an ontology for phases and steps of laparoscopic Roux-en-Y gastric bypass (LRYGB) is proposed and validated on a multicentric dataset in terms of inter- and intra-rater reliability (inter-/intra-RR). METHODS: The proposed LRYGB ontology consists of 12 phase and 46 step definitions that are hierarchically structured. Two board certified surgeons (raters) with > 10 years of clinical experience applied the proposed ontology on two datasets: (1) StraBypass40 consists of 40 LRYGB videos from Nouvel Hôpital Civil, Strasbourg, France and (2) BernBypass70 consists of 70 LRYGB videos from Inselspital, Bern University Hospital, Bern, Switzerland. To assess inter-RR the two raters' annotations of ten randomly chosen videos from StraBypass40 and BernBypass70 each, were compared. To assess intra-RR ten randomly chosen videos were annotated twice by the same rater and annotations were compared. Inter-RR was calculated using Cohen's kappa. Additionally, for inter- and intra-RR accuracy, precision, recall, F1-score, and application dependent metrics were applied. RESULTS: The mean ± SD video duration was 108 ± 33 min and 75 ± 21 min in StraBypass40 and BernBypass70, respectively. The proposed ontology shows an inter-RR of 96.8 ± 2.7% for phases and 85.4 ± 6.0% for steps on StraBypass40 and 94.9 ± 5.8% for phases and 76.1 ± 13.9% for steps on BernBypass70. The overall Cohen's kappa of inter-RR was 95.9 ± 4.3% for phases and 80.8 ± 10.0% for steps. Intra-RR showed an accuracy of 98.4 ± 1.1% for phases and 88.1 ± 8.1% for steps. CONCLUSION: The proposed ontology shows an excellent inter- and intra-RR and should therefore be implemented routinely in phase and step annotation of LRYGB.

Mesh fixation to fascia during incisional hernia repair results in increased prevalence of pain at long-term follow up: a multicenter propensity score matched prospective observational study.

BACKGROUND: Patient-reported outcomes such as postoperative pain are critical for the evaluation of outcomes after incisional hernia repair. The aim of this study is to determine the long-term impact of mesh fixation on postoperative pain in patients operated by open and laparoscopic technique. METHODS: A multicenter prospective observational cohort study was conducted from September 2011 until March 2016 in nine hospitals across Switzerland. Patients undergoing elective incisional hernia repair were included in this study and stratified by either laparoscopic or open surgical technique. Propensity score matching was applied to balance the differences in baseline characteristics between the treatment groups. Clinical follow-up was conducted 3, 12 and 36 months postoperatively to detect hernia recurrence, postoperative pain and complications. RESULTS: Three-hundred-sixty-one patients were included into the study. No significant differences in hernia recurrence and pain at 3, 12 and 36 months postoperatively were observed when comparing the laparoscopic with the open treatment group. Mesh fixation by sutures to fascia versus other mesh fixation led to significantly more pain at 36 months postoperatively (32.8% vs 15.7%, p = 0.025). CONCLUSIONS: At long-term follow-up, no difference in pain was identified between open and laparoscopic incisional hernia repair. Mesh fixation by sutures to fascia was identified to be associated with increased pain 36 months after surgery. Omitting mesh fixation by sutures to the fascia may reduce long-term postoperative pain after hernia repair.

Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study.

BACKGROUND: Multiple acute care surgery (ACS) working models have been implemented. To optimize resources and on-call rosters, knowledge about work characteristics is required. Therefore, this study aimed to investigate the daily work characteristics of ACS surgeons at a Swiss tertiary care hospital. METHODS: Single-center prospective snapshot study. In February 2020, ACS fellows prospectively recorded their work characteristics, case volume and surgical case mix for 20 day shifts and 16 night shifts. Work characteristics were categorized in 11 different activities and documented in intervals of 30 min. Descriptive statistics were applied. RESULTS: A total of 432.5 working hours (h) were documented and characterized. The three main activities 'surgery,' 'patient consultations' and 'administrative work' ranged from 30.8 to 35.9% of the documented working time. A total of 46 surgical interventions were performed. In total, during day shifts, there were 16 elective and 15 emergency interventions, during night shifts 15 emergency interventions. For surgery, two peaks between 10:00 a.m.-02:00 p.m. and 08:00 p.m.-11:00 p.m. were observed. A total of 225 patient were consulted, with a first peak between 08:00 a.m. and 11:00 a.m. and a second, wider peak between 02:00 p.m. and 02:00 a.m. CONCLUSION: The three main activities 'surgery,' 'patient consultations' and 'administrative work' were comparable with approximately one third of the working time each. There was a bimodal temporal distribution for both surgery and patient consultations. These results may help to improve hospital resources and on-call rosters of ACS services.

Impact of Inter-Hospital Transfer on Outcomes in Patients Undergoing Emergency Abdominal Surgery: A Tertiary Referral Center's Perspective.

BACKGROUND: In trauma patients, the impact of inter-hospital transfer has been widely studied. However, for patients undergoing emergency abdominal surgery (EAS), the effect of inter-hospital transfer on outcomes is largely unknown. METHODS: This is a single-center, retrospective observational study. Outcomes of transferred patients undergoing EAS were compared to patients primarily admitted to a tertiary care hospital from 01/2016 to 12/2018 using univariable and multivariable analyses. The primary outcome was in-hospital mortality. RESULTS: Some 973 patients with a median (IQR) age of 58.1 (39.4-72.2) years and a median body mass index of 25.8 (22.5-29.3) kg/m2 were included. The transfer group comprised 258 (26.3%) individuals and the non-transfer group 715 (72.7%). The population was stratified in three subgroups: (1) patients with low surgical stress (n = 483, 49.6%), (2) with hollow viscus perforation (n = 188, 19.3%) and (3) with potential bowel ischemia (n = 302, 31.1%). Neither in the low surgical stress nor in the hollow viscus perforation group was the transfer status associated with mortality. However, in the potential bowel ischemia group inter-hospital transfer was a predictor for mortality (OR 3.54, 95%CI 1.03-12.12, p = 0.045). Moreover, in the hollow viscus perforation group inter-hospital transfer was a predictor for reduced hospital length of stay (RC -10.02, 95%CI -18.14/-1.90, p = 0.016) and reduced severe complications (OR 0.38, 95%CI 0.18-0.77, p = 0.008). CONCLUSION: Other than in patients with low surgical stress or hollow viscus perforation, in patients with potential bowel ischemia inter-hospital transfer was an independent predictor for higher mortality. Taking into account the time sensitiveness of bowel ischemia, efforts should be made to avoid inter-hospital transfer in this vulnerable subgroup of patients.

Oncologic long-term outcomes of emergency versus elective resection for colorectal cancer.

PURPOSE: Long-term outcomes in patients undergoing emergency versus elective resection for colorectal cancer (CRC) are discussed controversially. This study aims to assess long-term outcomes of emergency versus elective CRC surgery. METHODS: Single-center retrospective cohort study. Patients undergoing emergency or elective CRC surgery from July 2002 to January 2013 were included. Primary outcome was 5-year survival, secondary outcomes were in-hospital mortality and local tumor recurrence. RESULTS: Overall, 475 patients were included. Median age was 69.0 (IQR 59.0-77.0) years. A total of 141 patients (30%) were operated for rectal cancer and 334 patients (70%) for colon cancer. Median follow-up was 445 (IQR 67-1409) days. Emergency resection was performed in 105 patients (22%) due to obstruction, perforation, or bleeding. Stage IV tumors and ASA scores≥ 3 were significantly more frequent in the emergency than in the elective resection group (39.0% vs. 33.5%, p < 0.001; 75.5% vs. 61.3%, p = 0.003). The rate of patients with positive lymph nodes was similar in the two groups (46.2% vs. 46.3%, p = 1.000). In-hospital mortality was significantly higher in the emergency CRC versus the elective CRC group (8.4% vs. 3.0%, p = 0.023). Five-year survival (aHR 1.38; 95%CI 0.81-2.37, p = 0.237) or local tumor recurrence (aHR 1.48; 95%CI 0.47-4.66, p = 0.500) were not significantly different in patients undergoing emergency versus elective surgery for CRC. CONCLUSION: In-hospital mortality was increased in emergency versus elective CRC resections. However, 5-year survival and local recurrence after surgery for CRC were determined by the tumor stage, and not by the emergency versus elective setting of surgical resection.

Long-term results of laparoscopic versus open intraperitoneal onlay mesh incisional hernia repair: a propensity score-matched analysis.

BACKGROUND: Intraperitoneal onlay mesh repair (IPOM) of incisional hernia is performed by laparoscopic and open access. The aim of the present study is to compare open versus laparoscopic surgery specifically using an IPOM technique for incisional hernia repair. METHODS: A propensity score-matched observational single center study of patients that underwent IPOM between 2004 and 2015 was conducted. The primary outcome was hernia recurrence; secondary outcomes include length of stay, surgical site infections (SSI), complications, and localization of recurrence. RESULTS: Among 553 patients with incisional hernia repair, 59% underwent laparoscopic and 41% open IPOM. A total of 184 patients completed follow-up. After a mean follow-up of 5.5 years recurrence rate was 20% in laparoscopic and 19% in open repair (p = 1.000). Patients undergoing laparoscopic IPOM had significantly reduced operation time (median 120 vs. 180 min, p < 0.001), shorter hospital stays (6 vs. 8 days, p = 0.002), less complications (10 vs. 23%, p = 0.046), and fewer SSI (1 vs. 21%, p < 0.001). CONCLUSIONS: Laparoscopic IPOM is associated with reduced morbidity compared to open IPOM for incisional hernia repair.

[Prophylaxis of incisional hernia - Are they preventable?] / Prophylaxe von Narbenhernien ­ Lassen sie sich verhindern?

Prophylaxis of incisional hernia - Are they preventable? Abstract. Following abdominal surgery, incisional hernias are common. Weight reduction and smoking cessation prior to elective surgery positively influence relevant risk factors. Laparoscopic operation technique prevents incisional hernia formation. Patients at increased risk for incisional hernia undergoing open abdominal surgery should be evaluated for prophylactic implantation of a non-absorbable mesh.

[Sequelae of hernia repair: What are the key issues?] / Folgezustände nach Hernienchirurgie: Was ist zu beachten?

Sequelae of hernia repair: What are the key issues? Abstract. Since hernia repair is increasingly performed as day case surgery, general practitioners are becoming progressively involved in postoperative care. Early sequelae must be differentiated from late sequelae of hernia repair. Hematomas, seromas and acute pain are frequent early postoperative problems, while at a later stage recurrence and potentially chronifying pain are of importance. The focus of this review is on aftercare, frequent postoperative problems and their therapeutic options.

Advancing surgical VQA with scene graph knowledge.

PURPOSE: The modern operating room is becoming increasingly complex, requiring innovative intra-operative support systems. While the focus of surgical data science has largely been on video analysis, integrating surgical computer vision with natural language capabilities is emerging as a necessity. Our work aims to advance visual question answering (VQA) in the surgical context with scene graph knowledge, addressing two main challenges in the current surgical VQA systems: removing question-condition bias in the surgical VQA dataset and incorporating scene-aware reasoning in the surgical VQA model design. METHODS: First, we propose a surgical scene graph-based dataset, SSG-VQA, generated by employing segmentation and detection models on publicly available datasets. We build surgical scene graphs using spatial and action information of instruments and anatomies. These graphs are fed into a question engine, generating diverse QA pairs. We then propose SSG-VQA-Net, a novel surgical VQA model incorporating a lightweight Scene-embedded Interaction Module, which integrates geometric scene knowledge in the VQA model design by employing cross-attention between the textual and the scene features. RESULTS: Our comprehensive analysis shows that our SSG-VQA dataset provides a more complex, diverse, geometrically grounded, unbiased and surgical action-oriented dataset compared to existing surgical VQA datasets and SSG-VQA-Net outperforms existing methods across different question types and complexities. We highlight that the primary limitation in the current surgical VQA systems is the lack of scene knowledge to answer complex queries. CONCLUSION: We present a novel surgical VQA dataset and model and show that results can be significantly improved by incorporating geometric scene features in the VQA model design. We point out that the bottleneck of the current surgical visual question-answer model lies in learning the encoded representation rather than decoding the sequence. Our SSG-VQA dataset provides a diagnostic benchmark to test the scene understanding and reasoning capabilities of the model. The source code and the dataset will be made publicly available at: https://github.com/CAMMA-public/SSG-VQA .

Challenges in multi-centric generalization: phase and step recognition in Roux-en-Y gastric bypass surgery.

PURPOSE: Most studies on surgical activity recognition utilizing artificial intelligence (AI) have focused mainly on recognizing one type of activity from small and mono-centric surgical video datasets. It remains speculative whether those models would generalize to other centers. METHODS: In this work, we introduce a large multi-centric multi-activity dataset consisting of 140 surgical videos (MultiBypass140) of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgeries performed at two medical centers, i.e., the University Hospital of Strasbourg, France (StrasBypass70) and Inselspital, Bern University Hospital, Switzerland (BernBypass70). The dataset has been fully annotated with phases and steps by two board-certified surgeons. Furthermore, we assess the generalizability and benchmark different deep learning models for the task of phase and step recognition in 7 experimental studies: (1) Training and evaluation on BernBypass70; (2) Training and evaluation on StrasBypass70; (3) Training and evaluation on the joint MultiBypass140 dataset; (4) Training on BernBypass70, evaluation on StrasBypass70; (5) Training on StrasBypass70, evaluation on BernBypass70; Training on MultiBypass140, (6) evaluation on BernBypass70 and (7) evaluation on StrasBypass70. RESULTS: The model's performance is markedly influenced by the training data. The worst results were obtained in experiments (4) and (5) confirming the limited generalization capabilities of models trained on mono-centric data. The use of multi-centric training data, experiments (6) and (7), improves the generalization capabilities of the models, bringing them beyond the level of independent mono-centric training and validation (experiments (1) and (2)). CONCLUSION: MultiBypass140 shows considerable variation in surgical technique and workflow of LRYGB procedures between centers. Therefore, generalization experiments demonstrate a remarkable difference in model performance. These results highlight the importance of multi-centric datasets for AI model generalization to account for variance in surgical technique and workflows. The dataset and code are publicly available at https://github.com/CAMMA-public/MultiBypass140.

Preserving privacy in surgical video analysis using a deep learning classifier to identify out-of-body scenes in endoscopic videos.

Surgical video analysis facilitates education and research. However, video recordings of endoscopic surgeries can contain privacy-sensitive information, especially if the endoscopic camera is moved out of the body of patients and out-of-body scenes are recorded. Therefore, identification of out-of-body scenes in endoscopic videos is of major importance to preserve the privacy of patients and operating room staff. This study developed and validated a deep learning model for the identification of out-of-body images in endoscopic videos. The model was trained and evaluated on an internal dataset of 12 different types of laparoscopic and robotic surgeries and was externally validated on two independent multicentric test datasets of laparoscopic gastric bypass and cholecystectomy surgeries. Model performance was evaluated compared to human ground truth annotations measuring the receiver operating characteristic area under the curve (ROC AUC). The internal dataset consisting of 356,267 images from 48 videos and the two multicentric test datasets consisting of 54,385 and 58,349 images from 10 and 20 videos, respectively, were annotated. The model identified out-of-body images with 99.97% ROC AUC on the internal test dataset. Mean ± standard deviation ROC AUC on the multicentric gastric bypass dataset was 99.94 ± 0.07% and 99.71 ± 0.40% on the multicentric cholecystectomy dataset, respectively. The model can reliably identify out-of-body images in endoscopic videos and is publicly shared. This facilitates privacy preservation in surgical video analysis.

Increased hospital treatment volume of splenic injury predicts higher rates of successful non-operative management and reduces hospital length of stay: a Swiss Trauma Registry analysis.

PURPOSE: First time analysis of the epidemiology, management and outcomes of patients with splenic injuries in Switzerland. This study aims to assess the effect of hospital treatment volume on successful non-operative management (NOM) in splenic injuries. METHODS: A multicentric registry-based study including all patients with splenic injuries entered into the Swiss Trauma Registry from 2015 to 2018 was conducted. Patients were stratified according to the hospitals treatment volume of splenic injuries. Primary outcome was the rate of successful NOM. RESULTS: During the 4-year study period, 652 patients with splenic injury were included in the study. Median age of the study population was 42 (IQR 27-59) years, and median ISS was 26 (20-34). The overall rate of successful NOM was 86.5%. Median HLOS was 13 (8-21) days. In-hospital mortality was 7.2% (n = 47). The mean number of patients with splenic injuries per center and year was 14. Five out of 12 Level I trauma centers treating more patients than the mean (≥ 15/year) were defined as high-volume centers. Multivariable analysis adjusting for differences in baseline and injury characteristics revealed treatment in a high-volume center as an independent predictor for successful NOM (OR 2.15, 95% CI 1.28-3.60, p = 0.004) and shorter HLOS (RC - 2.39, 95% CI - 4.91/- 0.48, p = 0.017), however, not for reduced in-hospital mortality (OR 0.92, 95% CI 0.39-2.18, p = 0.845). CONCLUSION: Higher hospital treatment volume was associated with a higher rate of NOM and shorter HLOS, but not lower mortality. These results constitute the basis for further quality improvement in the care of splenic injury patients within the trauma system in Switzerland.

ClipAssistNet: bringing real-time safety feedback to operating rooms.

PURPOSE: Cholecystectomy is one of the most common laparoscopic procedures. A critical phase of laparoscopic cholecystectomy consists in clipping the cystic duct and artery before cutting them. Surgeons can improve the clipping safety by ensuring full visibility of the clipper, while enclosing the artery or the duct with the clip applier jaws. This can prevent unintentional interaction with neighboring tissues or clip misplacement. In this article, we present a novel real-time feedback to ensure safe visibility of the instrument during this critical phase. This feedback incites surgeons to keep the tip of their clip applier visible while operating. METHODS: We present a new dataset of 300 laparoscopic cholecystectomy videos with frame-wise annotation of clipper tip visibility. We further present ClipAssistNet, a neural network-based image classifier which detects the clipper tip visibility in single frames. ClipAssistNet ensembles predictions from 5 neural networks trained on different subsets of the dataset. RESULTS: Our model learns to classify the clipper tip visibility by detecting its presence in the image. Measured on a separate test set, ClipAssistNet classifies the clipper tip visibility with an AUROC of 0.9107, and 66.15% specificity at 95% sensitivity. Additionally, it can perform real-time inference (16 FPS) on an embedded computing board; this enables its deployment in operating room settings. CONCLUSION: This work presents a new application of computer-assisted surgery for laparoscopic cholecystectomy, namely real-time feedback on adequate visibility of the clip applier. We believe this feedback can increase surgeons' attentiveness when departing from safe visibility during the critical clipping of the cystic duct and artery.

Automation of surgical skill assessment using a three-stage machine learning algorithm.

Surgical skills are associated with clinical outcomes. To improve surgical skills and thereby reduce adverse outcomes, continuous surgical training and feedback is required. Currently, assessment of surgical skills is a manual and time-consuming process which is prone to subjective interpretation. This study aims to automate surgical skill assessment in laparoscopic cholecystectomy videos using machine learning algorithms. To address this, a three-stage machine learning method is proposed: first, a Convolutional Neural Network was trained to identify and localize surgical instruments. Second, motion features were extracted from the detected instrument localizations throughout time. Third, a linear regression model was trained based on the extracted motion features to predict surgical skills. This three-stage modeling approach achieved an accuracy of 87 ± 0.2% in distinguishing good versus poor surgical skill. While the technique cannot reliably quantify the degree of surgical skill yet it represents an important advance towards automation of surgical skill assessment.

Effectiveness of Prophylactic Intraperitoneal Mesh Implantation for Prevention of Incisional Hernia in Patients Undergoing Open Abdominal Surgery: A Randomized Clinical Trial.

Importance: Incisional hernia is a frequent complication after open abdominal surgery. Prophylactic mesh implantation in the onlay or sublay position requires dissection of the abdominal wall, potentially leading to wound-associated complications. Objective: To compare the incidence of incisional hernia among patients after prophylactic intraperitoneal mesh implantation with that among patients after standard abdominal closure. Design, Setting, and Participants: An open-label randomized clinical trial was performed in 169 patients undergoing elective open abdominal surgery from January 1, 2011, to February 29, 2014. Follow-up examinations were performed 1 year and 3 years after surgery. The study was conducted at Bern University Hospital, Bern, Switzerland, a referral center that offers the whole spectrum of abdominal surgical interventions. Patients with 2 or more of the following risk factors were included: overweight or obesity, diagnosis of neoplastic disease, male sex, or history of previous laparotomy. Patients were randomly assigned to prophylactic intraperitoneal mesh implantation or standard abdominal closure. Data were analyzed in August 2017. Interventions: Intraperitoneal implantation of a polypropylene-polyvinylidene fluoride mesh with circumferential fixation. Main Outcomes and Measures: The primary end point was the incidence of incisional hernia 3 years after surgery. Secondary end points included mesh-related complications. Results: After the exclusion of 19 patients, 150 patients (81 in the control group and 69 in the mesh group; mean [SD] age, 64.2 [11.1] years; 102 [68.0%] male) were studied. The cumulative incidence of incisional hernia was significantly lower in the mesh group compared with the control group (5 of 69 [7.2%] vs 15 of 81 [18.5%], log-rank test P = .03). Abdominal pain was observed in significantly more patients in the mesh group compared with the control group at 6 weeks (34 of 52 [65%] vs 26 of 59 [44%], P = .04) but not at 12 and 36 months postoperatively. No difference in surgical site infections was observed, but time to complete wound healing of surgical site infection was significantly longer in patients with mesh implantation (median [interquartile range], 8 [6-24] weeks compared with 5 [1-9] weeks; P = .03). Trunk extension was significantly decreased after mesh implantation compared with the control group (mean [SD], 1.73 [0.97] cm vs 2.40 [1.23] cm, P = .009). Conclusions and Relevance: In patients at elevated risk for incisional hernia, prophylactic intraperitoneal mesh implantation reduces the incidence of hernia formation but with increased early postoperative pain and prolonged wound healing of surgical site infection. Trial Registration: ClinicalTrials.gov Identifier: NCT01203553.

Outcomes of emergency abdominal surgery in octogenarians: A single-center analysis.

BACKGROUND: The aim of this study was to assess outcomes of octogenarians undergoing emergency abdominal surgery (EAS). METHODS: Octogenarians undergoing EAS 12/2011-12/2016 were retrospectively analysed. The outcomes were assessed by univariable and multivariable regression analysis. RESULTS: One-hundred-forty patients with a median age of 83.9 years were included. EAS was performed for cholecystitis (27.1%), ileus (22.1%), hollow viscus perforation (16.4%), diverticulitis (12.9%), mesenteric ischemia (10.0%), incarcerated hernia (9.3%), and appendicitis (2.1%). The overall and early (within 7 days from surgery) mortality rate was 16.4% and 10.0%, respectively. Multivariable analysis revealed age (OR 1.24,CI95% 1.04-1.47,p = 0.015), ASA scores≥4 (OR 11.15,CI95% 2.39-52.02,p = 0.002), mesenteric ischemia (OR 52.60,CI95% 8.93-309.94,p < 0.001) and ICU admission (OR 9.23,CI95% 1.74-49.04,p = 0.009) as independent predictors for mortality. Postoperative withdrawal of care accounted for 36% of early mortalities. CONCLUSIONS: One third of early mortality in octogenarians was due to postoperative withdrawal of care. An interdisciplinary decision-making including patients' and relatives' wishes may avoid ethically questionable interventions in octogenarians.