Impact of the establishment of a specialty hernia referral center.

BACKGROUND: Creating a surgical specialty referral center requires a strong interest, expertise, and a market demand in that particular field, as well as some form of promotion. In 2004, we established a tertiary hernia referral center. Our goal in this study was to examine its impact on institutional volume and economics. MATERIALS AND METHODS: The database of all hernia repairs (2004-2011) was reviewed comparing hernia repair type and volume and center financial performance. The ventral hernia repair (VHR) patient subset was further analyzed with particular attention paid to previous repairs, comorbidities, referral patterns, and the concomitant involvement of plastic surgery. RESULTS: From 2004 to 2011, 4927 hernia repairs were performed: 39.3% inguinal, 35.5% ventral or incisional, 16.2% umbilical, 5.8% diaphragmatic, 1.6% femoral, and 1.5% other. Annual billing increased yearly from 7% to 85% and averaged 37% per year. Comparing 2004 with 2011, procedural volume increased 234%, and billing increased 713%. During that period, there was a 2.5-fold increase in open VHRs, and plastic surgeon involvement increased almost 8-fold, (P = .004). In 2005, 51 VHR patients had a previous repair, 27.0% with mesh, versus 114 previous VHR in 2011, 58.3% with mesh (P < .0001). For VHR, in-state referrals from 2004 to 2011 increased 340% while out-of-state referrals jumped 580%. In 2011, 21% of all patients had more than 4 comorbidities, significantly increased from 2004 (P = .02). CONCLUSION: The establishment of a tertiary, regional referral center for hernia repair has led to a substantial increase in surgical volume, complexity, referral geography, and financial benefit to the institution.

The efficacy and morbidity of different surgical treatment techniques for chronic anal fissure: an academic colorectal experience.

Up to 40 per cent of chronic fissures will fail to heal with medical treatment alone. Open (OLIS) and closed (CLIS) lateral internal sphincterotomies are considered by many to be the treatment of choice for chronic anal fissures (CAF). The aim of this study was to compare the efficacy and clinical outcomes of different surgical techniques for treatment of CAF. We performed a retrospective chart review of 387 patients with CAF who underwent surgical intervention performed by colorectal surgeons between 2006 and 2012 at Greenville Hospital System. Of 387 patients, 199 underwent OLIS, 124 CLIS, and 64 patients underwent fissurectomy alone (FE). We investigated the effect of the surgical technique on time of healing, rate of flatus incontinence, wound infection, recurrence, and the need for additional intervention. There was no statistically significant difference among patients undergoing OLIS, CLIS, and FE in demographic characteristic, time of healing, rate of wound infections, and fecal continence, or recurrence rate. Comparison of a combined lateral internal sphincterotomy (LIS) group with FE showed that there is similar time of healing (P = 0.58), no statistical difference in flatus incontinence rate (P = 0.61), urinary retention (P = 1.0), fissure recurrence (P = 0.11), and prolonged healing (P = 0.2). Patients in FE group more likely required additional treatment to complete wound healing (P = 0.02). LIS is a safe and effective technique for treatment of CAF. Although there was no difference in complications rate and healing time, patients in the FE group required additional surgical or medical treatment more frequently to achieve complete healing.

Antibacterial mesh: a novel technique involving naturally occurring cellular proteins.

BACKGROUND: Naturally occurring antimicrobial peptides are possibly the "next frontier" in infection prevention. Binding them to mesh could reduce the rate of mesh infections. This study identifies an antimicrobial agent capable of significant antibacterial activity when bound to mesh. METHODS: Lysozyme, human beta defensin (HBD-3), human cathelicidin (LL-37), and lysostaphin were adsorbed to polypropylene mesh at various concentrations. Treated meshes were placed in a suspension of 1 × 10(6) Staphylococcus aureus. Antibacterial action was monitored by turbidimetric assay, fluorescent imaging, and a colony counting method. RESULTS: A very high rate of lysis of S aureus cells was observed in the lysostaphin-treated group as measured by optical density; none survived as seen on colony count assays. Optical density for mesh coated with lysozyme, HBD-3, and LL-37 did not differ from untreated controls, with 100% survival rates by colony counts. CONCLUSION: Lysostaphin had superior antibacterial activity following adsorption to mesh.

Evaluation of the antimicrobial activity of lysostaphin-coated hernia repair meshes.

Bacterial infections by antibiotic-resistant Staphylococcus aureus strains are among the most common postoperative complications in surgical hernia repair with synthetic mesh. Surface coating of medical devices/implants using antibacterial peptides and enzymes has recently emerged as a potentially effective method for preventing infections. The objective of this study was to evaluate the in vitro antimicrobial activity of hernia repair meshes coated by the antimicrobial enzyme lysostaphin at different initial concentrations. Lysostaphin was adsorbed on pieces of polypropylene (Ultrapro) mesh with binding yields of ∼10 to 40% at different coating concentrations of between 10 and 500 µg/ml. Leaching of enzyme from the surface of all the samples was studied in 2% (wt/vol) bovine serum albumin in phosphate-buffered saline buffer at 37°C, and it was found that less than 3% of adsorbed enzyme desorbed from the surface after 24 h of incubation. Studies of antibacterial activity against a cell suspension of S. aureus were performed using turbidity assay and demonstrated that the small amount of enzyme leaching from the mesh surface contributes to the lytic activity of the lysostaphin-coated samples. Colony counting data from the broth count (model for bacteria in wound fluid) and wash count (model for colonized bacteria) for the enzyme-coated samples showed significantly decreased numbers of CFU compared to uncoated samples (P < 0.05). A pilot in vivo study showed a dose-dependent efficacy of lysostaphin-coated meshes in a rat model of S. aureus infection. The antimicrobial activity of the lysostaphin-coated meshes suggests that such enzyme-leaching surfaces could be efficient at actively resisting initial bacterial adhesion and preventing subsequent colonization of hernia repair meshes.

Increased stress levels may explain the incomplete transfer of simulator-acquired skill to the operating room.

BACKGROUND: Proficiency-based simulator training in laparoscopic suturing leads to improved operative performance, but the skill transfer is incomplete. The objective of this study was to examine the stress level of trainees during the transition from the simulator to the operating room (OR) and its impact on performance. METHODS: Novices (n = 20) were randomized into training and control groups. After the training group achieved proficiency in laparoscopic suturing, both groups were tested on a live porcine, laparoscopic Nissen fundoplication model. Participant performance was assessed using an objective score. Stress level was evaluated by recording beat-to-beat heart rate (BBHR) and short-term heart rate variability (STHRV) at baseline, after achieving proficiency (only the training group) and in the OR. Repeated measurement analysis of variance (ANOVA) and t test were used for analysis. RESULTS: Baseline simulator performance and data for heart rate variability were similar for both groups. After achieving simulator proficiency, the trained group demonstrated the anticipated decrease in performance (mean average + or - SEM) in the OR (524 + or - 17 vs 290 + or - 95; P < .001), and an increase in BBHR (98 + or - 14 vs115 + or - 18; P < .001) but not STHRV (4.1 + or - 0.8 vs 3.7 + or - 0.9; P = .5). A similar but lesser increase of the BBHR was observed in the control group compared to the study group. CONCLUSION: BBHR was a more sensitive measure of stress level compared with STHRV. The increased BBHR observed in the OR that reflects stress and performance anxiety may explain the incomplete transfer of simulator-acquired skill in novice learners.

Higher mental workload is associated with poorer laparoscopic performance as measured by the NASA-TLX tool.

INTRODUCTION: Increased workload during task performance may increase fatigue and facilitate errors. The National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a previously validated tool for workload self-assessment. We assessed the relationship of workload and performance during simulator training on a complex laparoscopic task. METHODS: NASA-TLX workload data from three separate trials were analyzed. All participants were novices (n = 28), followed the same curriculum on the fundamentals of laparoscopic surgery suturing model, and were tested in the animal operating room (OR) on a Nissen fundoplication model after training. Performance and workload scores were recorded at baseline, after proficiency achievement, and during the test. Performance, NASA-TLX scores, and inadvertent injuries during the test were analyzed and compared. RESULTS: Workload scores declined during training and mirrored performance changes. NASA-TLX scores correlated significantly with performance scores (r = -0.5, P < 0.001). Participants with higher workload scores caused more inadvertent injuries to adjacent structures in the OR (r = 0.38, P < 0.05). Increased mental and physical workload scores at baseline correlated with higher workload scores in the OR (r = 0.52-0.82; P < 0.05) and more inadvertent injuries (r = 0.52, P < 0.01). CONCLUSIONS: Increased workload is associated with inferior task performance and higher likelihood of errors. The NASA-TLX questionnaire accurately reflects workload changes during simulator training and may identify individuals more likely to experience high workload and more prone to errors during skill transfer to the clinical environment.