Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure.

BACKGROUND: The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. METHODS: Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. RESULTS: A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44-78)]. Subject matter experts practiced a median of 6.5 years (1.5-16) and have completed a median of 300 (60-500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. CONCLUSION: This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

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

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

Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model.

BACKGROUND: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model. METHODS: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann-Whitney U test. Values are represented as average myofascial medialization in centimeters. RESULTS: Following MLL an average of 5.0 ± 0.9 cm (range 3.4-6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3-10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6-12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535. CONCLUSIONS: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen.

Robotic-Assisted Transabdominal Preperitoneal Ventral Hernia Repair.

Ventral hernia repair is one of the most common operations performed by surgeons worldwide. The widespread adoption of laparoscopic surgery has significantly reduced complications related to traditional open approaches. The most common approach in laparoscopic ventral hernia repair is the intraperitoneal onlay mesh (IPOM) approach. This technique, though simple to perform, has limitations, including bridging mesh, intraperitoneal positioning of mesh, transfascial fixation, circumferential mesh fixation, and the use of more expensive composite mesh materials. These limitations are magnified when hernias occur in anatomically difficult sites such as the subxiphoid, suprapubic, and flank regions. Robotic-assisted hernia repair using a transabdominal preperitoneal (TAPP) approach has emerged as a viable alternative to traditional IPOM by potentially addressing these limitations. We review the operative considerations, intraoperative approach, and current body of literature related to robotic-assisted TAPP ventral hernia repair and conclude that it is feasible and may result in improved outcomes related to the restoration of abdominal wall anatomy and reduced operative costs. Further studies are needed to assess if robotic-assisted TAPP should become the standard approach for repair of ventral hernia defects.

A Single Surgeon's Experience With Transgender Female-to-Male Chest Surgery.

BACKGROUND: Chest wall recontouring is a common surgical treatment of gender dysphoria in transmen and nonbinary individuals assigned female at birth. This study reviews more than 20 years of cases to identify risk factors for postoperative complications and likelihood of preservation of nipple sensation. METHODS: One hundred thirty-seven cases of female-to-male chest wall recontouring by a single surgeon from 1994 to 2016 were reviewed, 99 of which were included for final analysis. Double-incision free nipple graft and double incision with nipple transposition on a pedicle were the most common techniques used. Complication rates between these 2 techniques were compared, and multivariate analysis was used to identify possible predictors of major complications, and minor complications. RESULTS: No significant risk factors for major complications were identified. With regard to minor complications, advanced patient age (odds ratio [OR], 1.67; P = 0.03) and early surgical experience (OR, 5.08; P = 0.001) were found to be associated with increased risk. Preoperative hormonal treatment was found to trend toward a protective effect (OR, 0.13; P = 0.07). CONCLUSIONS: Any of the reviewed techniques are safe in practice; however, there is a learning curve associated with their use, and longer follow-up will allow for the identification of late complications. The double incision with nipple transposition on a pedicle technique can be considered for patients for whom depigmentation of the nipple-areola complex is a significant concern, especially if they are willing to tolerate a potentially suboptimal chest contour.

Comparison of stricture rates using three different gastrojejunostomy anastomotic techniques in laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: No single gastrojejunostomy anastomosis technique (GJA) in Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently preferred over another. Bendewald et al. confirmed that there was no difference in anastomotic stricture rates when comparing hand-sewn (HS), linear-stapled (LS), and circular-stapled (CS) GJA techniques. We present and analyze our own institutional data to readdress stricture rates. METHODS: From January 2010 to January 2013, 860 consecutive patients underwent LRYGB using HS, LS, and CS anastomotic techniques at a single institution. All patients in this study were followed to see if they had a complication of a stricture within this time period. Hospital records were retrospectively reviewed and those who had stricture complications shown on endoscopy requiring intervention were compiled and compared using univariate analysis. RESULTS: Patient demographics did not differ substantially between the three groups. The most common technique employed was LS (n = 429, 49.8%), followed by CS (n = 254, 29.5%) and HS (n = 177, 20.6%), respectively. Using multivariate analysis, there was a significant difference in the rate of strictures between the anastomotic techniques (LS 4.42%, HS 2.82%, CS 1.18%, p = 0.0163). CONCLUSIONS: Our data show that the discussion of which anastomotic technique is superior should be reopened given the statistically significant low rate of strictures in patients who underwent LRYGB with a CS anastomosis in comparison with LS and HS anastomoses.

Structured Resident Training in Robotic Surgery: Recommendations of the Robotic Surgery Education Working Group.

OBJECTIVE: A universal resident robotic surgery training pathway that maximizes proficiency and safety has not been defined by a consensus of surgical educators or by surgical societies. The objective of the Robotic Surgery Education Working Group was to develop a universal curriculum pathway and leverage digital tools to support resident education. DESIGN: The two lead authors (JP and YN) contacted potential members of the Working Group. Members were selected based on their authorship of peer-review publications, their experience as minimally invasive and robotic surgeons, their reputations, and their ability to commit the time involved to work collaboratively and efficiently to reach consensus regarding best practices in robotic surgery education. The Group's approach was to reach 100% consensus to provide a transferable curriculum that could be applied to the vast majority of resident programs. SETTING: Virtual and in-person meetings in the United States. PARTICIPANTS: Eight surgeons (2 females and 6 males) from five academic medical institutions (700-1541 beds) and three community teaching hospitals (231-607 beds) in geographically diverse locations comprised the Working Group. They represented highly specialized general surgeons and educators in their mid-to-late careers. All members were experienced minimally invasive surgeons and had national reputations as robotic surgery educators. RESULTS: The surgeons initially developed and agreed upon questions for each member to consider and respond to individually via email. Responses were collated and consolidated to present on an anonymized basis to the Group during an in-person day-long meeting. The surgeons self-facilitated and honed the agreed upon responses of the Group into a 5-level Robotic Surgery Curriculum Pathway, which each member agreed was relevant and expressed their convictions and experience. CONCLUSIONS: The current needs for a universal robotic surgery training curriculum are validated objective and subjective measures of proficiency, access to simulation, and a digital platform that follows a resident from their first day of residency through training and their entire career. Refinement of current digital solutions and continued innovation guided by surgical educators is essential to build and maintain a scalable, multi-institutional supported curriculum.

Antidepressant-selective gynecomastia.

OBJECTIVE: To describe what we believe is the first reported case of synergistic gynecomastia during treatment of depressive and anxiety disorders when sertraline was added to a stable medication regimen including duloxetine, rosuvastatin, and amlodipine. CASE SUMMARY: A 67-year-old male with major depression, dysthymia, obsessive-compulsive disorder, social anxiety, hypertension, diabetes, and hyperlipidemia presented with new-onset gynecomastia and breast tenderness. Mammography revealed bilateral gynecomastia (fibroglandular tissue posterior to the nipples bilaterally) without suspicious mass, calcification, or other abnormalities. These new symptoms developed after sertraline was added to his stable medication regimen (duloxetine, alprazolam, rosuvastatin, metoprolol, amlodipine, hydrochlorothiazide/triamterene, metformin, and sitagliptin). These symptoms were dose-dependent, with gynecomastia and breast tenderness more severe as sertraline was titrated from 25 mg/day to 50 mg/day and then to 75 mg/day. When sertraline was discontinued, gynecomastia and breast tenderness rapidly resolved. DISCUSSION: Mammoplasia and gynecomastia are associated with altered dopamine neurotransmission and/or perturbations in sexual hormones. These adverse effects may be medication induced. Selective serotonin reuptake inhibitors (sertraline), serotonin-norepinephrine reuptake inhibitors (duloxetine), rosuvastatin, and amlodipine have been reported to cause these adverse effects. This case was unique, since the patient had been on both sertraline and duloxetine previously as independent psychotropics without the development of gynecomastia. In the context of an additive drug adverse effect, the probability of sertraline as the precipitant drug was determined by both the Naranjo probability scale and the Horn drug interaction probability scale as probable. CONCLUSIONS: Gynecomastia is associated with antidepressants and other medications but is rarely addressed. Gynecomastia may be antidepressant selective or may be the result of additive adverse effects. Clinicians are advised to question patients regarding this potential adverse effect. Further education of clinicians is indicated.

Robotic Inguinal Hernia Repair.

Robotic inguinal hernia repair represents the natural progression of minimally invasive inguinal hernia surgery. This article highlights all aspects of a robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair with mesh, starting with preoperative planning and patient selection, key technical steps, and common postoperative complications and recovery. The most recent published data on robotic inguinal hernia repair are comprehensively reviewed, confirming that rTAPP is a safe and effective option for the repair of unilateral and bilateral inguinal hernias.

Fatal COVID-19 in an MS patient on natalizumab: A case report.

We report a fatal case of COVID-19 in a 51-year-old African American woman with multiple sclerosis on natalizumab. She had multiple risk factors for severe COVID-19 disease including race, obesity, hypertension, and elevated inflammatory markers, but the contribution of natalizumab to her poor outcome remains unknown. We consider whether altered dynamics of peripheral immune cells in the context of natalizumab treatment could worsen the cytokine storm syndrome associated with severe COVID-19. We discuss extended interval dosing as a risk-reduction strategy for multiple sclerosis patients on natalizumab, and the use of interleukin-6 inhibitors in such patients who contract COVID-19.

A Single-center Experience Examining the Length of Stay and Safety of Early Discharge After Laparoscopic Roux-en-Y Gastric Bypass Surgery.

PURPOSE: This study's objective was to describe our experience and evaluate the safety of early discharge (ED) following laparoscopic Roux-en-Y gastric bypass (LRYGB) in a specific patient population. MATERIALS AND METHODS: Patients undergoing LRYGB at Montefiore Medical Center were retrospectively reviewed. Patients readmitted in the first 30 days following surgery were compared to those patients who were not readmitted. Data analysis was used to compare groups and to determine factors associated with readmission. In addition to patient demographics, length of stay (LOS) was analyzed as an independent risk factor for readmission. RESULTS: A total of 630 LRYGB were performed during this period. There were 5.1% (n = 32) of patients that required readmission within 30 days of discharge. Readmitted patients had a higher BMI (50.0 vs. 45.8; p = 0.006) and there was a trend for them to be younger (38.4 years vs. 42.0; p = 0.07). There was an increased rate of ED in 2015 (36.7%, n = 121) compared to 2014 (29.9%, n = 90). The readmission rate for ED for the study period was 4.7% (n = 10). There were no observed mortalities in our early discharge group of patients. CONCLUSIONS: Discharge on post-operative day 1 following a LRYGB is safe and is not associated with an increased likelihood of being readmitted within 30 days of discharge. Our single-center experience helps to better characterize current patient profiles and length of stay trends within the field and can be used to establish a randomized controlled trial for discharging patients early after LRYGB.