The Advanced Certifying Exam Simulation-Pro assessment instrument: evaluating surgical trainee examsmanship in virtual oral exams.

Purpose: In response to the COVID-19 pandemic, many educational activities in general surgery residency have shifted to a virtual environment, including the American Board of Surgery (ABS) Certifying Exam. Virtual exams may become the new standard. In response, we developed an evaluation instrument, the ACES-Pro, to assess surgical trainee performance with a focus on examsmanship in virtual oral board examinations. The purpose of this study was two-fold: (1) to assess the utility and validity of the evaluation instrument, and (2) to characterize the unique components of strong examsmanship in the virtual setting, which has distinct challenges when compared to in-person examsmanship. Methods: We developed a 15-question evaluation instrument, the ACES-Pro, to assess oral board performance in the virtual environment. Nine attending surgeons viewed four pre-recorded oral board exam scenarios and scored examinees using this instrument. Evaluations were compared to assess for inter-rater reliability. Faculty were also surveyed about their experience using the instrument. Results: Pilot evaluators found the ACES-Pro instrument easy to use and felt it appropriately captured key professionalism metrics of oral board exam performance. We found acceptable inter-rater reliability in the domains of verbal communication, non-verbal communication, and effective use of technology (Guttmann's lambda-2 were 0.796, 0.916, and 0.739, respectively). Conclusions: The ACES-Pro instrument is an assessment with evidence for validity as understood by Kane's framework to evaluate multiple examsmanship domains in the virtual exam setting. Examinees must consider best practices for virtual examsmanship to perform well in this environment. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00107-7.

Operative dictations in surgical trainees: an underutilized educational resource?

INTRODUCTION: Accurate operative notes are imperative to patient care and are used for communication, billing, quality assurance, and medical-legal conflicts. However, operative note quality often varies and many lack critical details. Unfortunately, no standardized training exists in operative dictations for surgical trainees. This pilot study sought to determine resident ability to dictate a comprehensive operative note and to determine a need for a formal operative dictation curriculum. METHODS: Thirty-eight surgical residents between post-graduate years (PGY) one to four participated in a ventral hernia repair simulation. One senior (PGY3/4) resident coached two junior residents (PGY1/2). Residents completed an informal needs assessment regarding operative dictations. Post-simulation, residents completed an operative dictation. Notes were graded using a modified validated rubric. RESULTS: Thirty-five residents completed the needs assessment, and 38 residents submitted an operative note. Eighty-two percent of this group have completed ≤ 25 operative dictations in training and 77% have received minimal feedback on operative dictations. Out of 33 total points, mean overall score was 18.9 ± 5.4 (Junior resident: 17.9 ± 5.4; Senior resident: 20.9 ± 4.8) Total mean scores did not significantly differ between junior and senior residents (p = 0.10). Senior and junior residents scored similarly on the procedural details component (p = 0.29). Senior residents scored higher on relevant patient history and operative note headers (p = 0.04). CONCLUSION: Standard surgical training may not provide enough teaching and feedback to residents on operative note dictations. A formal residency training curriculum may bolster trainee ability to learn the components of an effective operative note.

SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM).

BACKGROUND: Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. METHODS: Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. RESULTS: The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. CONCLUSIONS: These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

COVID-19 Vaccination Status and Operative Outcomes after Kidney Transplantation.

BACKGROUND: Kidney transplantation remains the best available treatment for end-stage renal disease. However, promoting graft longevity and preventing allosensitization requires strict adherence with a stringent immunosuppression regimen. The COVID-19 pandemic has offered new challenges for kidney transplant patients and many transplant centers are denying transplantation to unvaccinated patients. The aim of this study was to evaluate whether unvaccinated patients had inferior adherence after kidney transplantation along with a reduction in graft survival. STUDY DESIGN: Patients undergoing a deceased donor kidney transplantation at a single academic medical center from February 2021 to May 2022 were retrospectively reviewed. February 2021 was chosen as the start date for record review because it was 3 months after the first COVID-19 vaccination was authorized for emergency use. Patients were considered to be vaccinated if they received at least 1 dose of any mRNA vaccine by their transplantation date. RESULTS: Of the 301 patients who met study criteria, 234 were vaccinated and 67 were unvaccinated. Cohorts stratified by vaccination status were well matched. Younger age was an independent risk factor for nonvaccination. Interestingly, unvaccinated patients had worse postoperative adherence with a greater average number of missed postoperative clinic visits (p = 0.03) and a strong trend toward missing 3 or more postoperative clinic visits (p = 0.07). Finally, unvaccinated patients had statistically more subtherapeutic tacrolimus troughs (p = 0.01). CONCLUSIONS: Patients not vaccinated against COVID-19 had higher rate of postoperative nonadherence in key areas of immunosuppression monitoring and clinic visit attendance. Providers should be cognizant that an unvaccinated status may be a harbinger for poor adherence; therefore, stricter strategies for patient outreach are critical to ensure graft success in this vulnerable patient population.

The efficacy of goal-directed recommendations in overcoming barriers to elective ventral hernia repair in older adults.

BACKGROUND: Although ventral hernias are common in older adults and can impair quality of life, multiple barriers exist that preclude ventral hernia repair. The goal of this study was to determine if older adults with ventral hernias achieve surgeon-directed goals to progress to an elective ventral hernia repair. METHODS: Patients ≥60 years evaluated for a ventral hernia in a specialty clinic from January 2018 to August 2021 were retrospectively reviewed. Nonoperative candidates with modifiable risk factors were included. Data collected included specific barriers to ventral hernia repair and recommendations to address these barriers for future ventral hernia repair eligibility. Patients lost to follow-up were contacted by phone. RESULTS: In total, 559 patients were evaluated, with 182 (32.6%) deemed nonoperative candidates with modifiable risk factors (median age 68 years, body mass index 38.2). Surgeon-directed recommendations included weight loss (53.8%), comorbidity management by a medical specialist (44.0%), and smoking cessation (19.2%). Ultimately, 45/182 patients (24.7%) met preoperative goals and progressed to elective ventral hernia repair. Alternatively, 5 patients (2.7%) required urgent/emergency surgical intervention. Importantly, 106/182 patients (58.2%) did not return to clinic after initial consultation. Of those contacted (n = 62), 35.5% reported failure to achieve optimization goals. Initial body mass index ≥40 and surgeon-recommended weight loss were associated with lack of patient follow-up (P = .01, P = .02) and progression to elective ventral hernia repair (P = .009, P = .005). CONCLUSION: Nearly one-third of older adults evaluated for ventral hernias were nonoperative candidates, most often due to obesity, and over half of these patients were lost to follow-up. An increase in structured support is needed for patients to achieve surgeon-specified preoperative goals.

Patient Factors Affect Ergonomic Strain of Endoscopists During Colonoscopy.

INTRODUCTION: Endoscopic procedures place a great deal of muscular strain on providers, especially over the span of their careers. In this study we quantitatively analyzed the effects of patient factors such as age, body mass index, and sex on the ergonomics of endoscopists performing colonoscopies. METHODS: Surface electromyography (sEMG) was used to measure ergonomic strain of physicians while performing colonoscopies in several key muscle groups. The percent of the maximum voluntary contraction (%MVC) was used as a measure of muscular strain. Data was then analyzed based on the patient characteristics above. RESULTS: Endoscopists performing colonoscopies on female patients (n = 47) experienced significantly higher ergonomic strain in their right trapezius and right posterior forearm muscle groups when compared to colonoscopies performed on males (n = 35) (%MVC R-trapezius: Male: 8.2; Female: 8.9; p = 0.048); (%MVC R-posterior forearm: Male: 10.4; Female: 11.6; p = 0.0006). Operators experienced greater strain in the same muscle groups when performing colonoscopies on patients with BMI ≤ 25 (n = 25) when compared to patients with BMI > 25 (n = 57) (%MVC R-trapezius: BMI < 25: 9.7; BMI ≥ 25: 8.2; p = 0.0002); (%MVC R-posterior forearm: BMI < 25: 11.9; BMI ≥ 25: 10.8; p = 0.0001). CONCLUSION: Physicians experienced greater ergonomic strain when performing colonoscopies on female patients and on patients with a BMI < 25. We believe that these factors potentially impact the tortuosity of the colon and therefore influence the difficulty of navigating the endoscope. These results may aid physicians in gauging the anticipated difficulty of colonoscopies based on patient factors. Increased awareness of their posturing and ergonomics during challenging cases will alleviate musculoskeletal injuries in the long run.

Translational design for limited resource settings as demonstrated by Vent-Lock, a 3D-printed ventilator multiplexer.

BACKGROUND: Mechanical ventilators are essential to patients who become critically ill with acute respiratory distress syndrome (ARDS), and shortages have been reported due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We utilized 3D printing (3DP) technology to rapidly prototype and test critical components for a novel ventilator multiplexer system, Vent-Lock, to split one ventilator or anesthesia gas machine between two patients. FloRest, a novel 3DP flow restrictor, provides clinicians control of tidal volumes and positive end expiratory pressure (PEEP), using the 3DP manometer adaptor to monitor pressures. We tested the ventilator splitter circuit in simulation centers between artificial lungs and used an anesthesia gas machine to successfully ventilate two swine. RESULTS: As one of the first studies to demonstrate splitting one anesthesia gas machine between two swine, we present proof-of-concept of a de novo, closed, multiplexing system, with flow restriction for potential individualized patient therapy. CONCLUSIONS: While possible, due to the complexity, need for experienced operators, and associated risks, ventilator multiplexing should only be reserved for urgent situations with no other alternatives. Our report underscores the initial design and engineering considerations required for rapid medical device prototyping via 3D printing in limited resource environments, including considerations for design, material selection, production, and distribution. We note that optimization of engineering may minimize 3D printing production risks but may not address the inherent risks of the device or change its indications. Thus, our case report provides insights to inform future rapid prototyping of medical devices.

Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: a systematic review and meta-analysis.

BACKGROUND: While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor. METHODS: PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD). RESULTS: From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17). CONCLUSIONS: Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.

Polypharmacy is predictive of postoperative complications in older adults undergoing ventral hernia repair.

BACKGROUND: Ventral hernias are common in older adults, and may be repaired via a transversus abdominus release (TAR). Older adults undergoing surgery have unique age-related risk factors, including polypharmacy. Polypharmacy is highly prevalent in older adults and is associated with adverse postoperative outcomes. Our aim was to examine the prevalence and association of polypharmacy with clinical outcomes in older adults undergoing a TAR. METHODS: Patients 60 years and older who underwent elective open or robotic bilateral TAR were included in the study. Average daily medications taken preoperatively was collected and stratified by tertiles. Baseline demographic data, peri- and postoperative outcomes, and 30-day outcomes were collected. RESULTS: There were 132 total patients with an average age of 67.8 years. The number of daily medications ranged from 0 to 28, with an overall mean of 11.2 medications. Patients in tertile 1 took an average of 5.3 medications, tertile 2 10.5 medications, and tertile 3 17.9 medications. Patients in tertile 3 had more than double the rate of in-hospital complications (0.7) compared to tertiles 1 and 2 (0.3 and 0.3, respectively; p = 0.03). A greater number of daily medications was independently associated with postoperative delirium [odds ratio (OR) 1.2, 95% confidence interval (CI) 1.0-1.3], cardiac events (OR 1.2, 95% CI 1.0-1.3), ICU stay (OR 1.2, 95% CI 1.0-1.3), and discharge to a skilled nursing facility (SNF) (OR 1.2, 95% CI 1.0-1.5). CONCLUSIONS: Polypharmacy was very common in older adults undergoing a TAR, and was associated with in-hospital complications, postoperative delirium, cardiac events, ICU stay, length of stay, and discharge to a SNF. Additional study is needed to assess if preoperative interventions to limit polypharmacy will improve outcomes for older adults undergoing a TAR.

Smaller hands and less experience are associated with greater ergonomic strain during endoscopic procedures.

INTRODUCTION: Up to 89% of physicians who routinely perform endoscopy experience some type of musculoskeletal pain. In this study, we sought to quantitatively analyze provider factors that influence ergonomic strain during live endoscopic procedures. METHODS: Surface electromyography (sEMG) was used to measure ergonomic strain on physicians while performing upper and lower endoscopies. EMG data were normalized to a maximal voluntary contraction (MVC) recording for each muscle group, yielding a %MVC value. Subgroup analyses were performed based on glove size, physician training level, specialty, and handedness. RESULTS: A total of 165 upper (n = 68) and lower (n = 97) endoscopies were recorded. Endoscopists with small hand sizes had significantly higher ergonomic strain in the left anterior and posterior forearm muscle compartments as compared to endoscopists with medium or large hands (%MVC L-anterior: small: 9.1 ± 1.1; medium: 6.4 ± 1.2; large: 5.9 ± 1.6; p < 0.001); (%MVC L-posterior: small: 12.0 ± 0.8; medium: 9.4 ± 1.3; large: 8.8 ± 1.4; p < 0.001). Additionally, upper body muscle groups had significantly higher ergonomic strain in endoscopists with less lifetime endoscopic experience (%MVC R-trapezius: expert: 8.4 ± 1.2; novice: 9.3 ± 1.2; p < 0.05); (%MVC R-deltoid: expert: 6.1 ± 1.4; novice: 8.5 ± 1.3; p < 0.001). There were no significant ergonomic differences between surgeons or gastroenterologists and no differences between right- and left-handed dominant individuals. CONCLUSIONS: Endoscopists with small hands experienced great ergonomic strain in their left forearm. Our data support the widely held belief that "one size does not fit all" and will hopefully spark change in the design of future endoscopes by device manufacturers. Our data also support that the experience level of the endoscopist contributed significantly to ergonomic performance, likely due to postural differences leading to decreased upper body strain. Therefore, it remains critically important to educate young proceduralists on strategies for ergonomic relief early in his or her endoscopic training program that can ameliorate ergonomic strain that accrues over the lifetime of a physician's career.

Perioperative outcomes of the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) program pilot for older hernia patients: does chronological age predict outcomes?

BACKGROUND: The Geriatric Assessment and Medical Preoperative Screening (GrAMPS) program was an initial attempt to understand and to define the prevalence of age-related risk factors in older patients undergoing elective ventral hernia repair (VHR) or inguinal hernia repair (IHR). Preliminary analysis found significant rates of previously unrecognized objective cognitive dysfunction, multimorbidity and polypharmacy. We now examine whether chronological age as a sole risk factor can predict a patient's perioperative outcomes, and if traditional risk calculators that rely heavily on chronological age can accurately capture a patient's true risk. METHODS: This was a retrospective secondary analysis of the previously reported GrAMPS trial enrolling patients 60 years and older with a planned elective repair of a ventral or inguinal hernia. The rates of key postoperative outcomes were compared between various cohorts stratified by chronological age. Previously validated risk screening calculators [Charlson Comorbidity Index (CCI), National Surgical Quality Improvement Program (NSQIP)] were compared between cohorts. RESULTS: In total, 55 (78.6%) of the 70 patients enrolled in GrAMPS underwent operative intervention by May 2021, including 26 VHR and 29 IHRs. Cohorts stratified by chronological age had similar rates of key perioperative wound and age-related outcomes including readmissions, postoperative complications, non-home discharges, and length of stay. Additionally, while the commonly used risk calculators, CCI and NSQIP, consistently predicted worse outcomes for older hernia patients (stratified by both median age and age-tertiles), screening positive on these risk assessments were not actually predictive of a greater incidence of postoperative complications. CONCLUSIONS: Chronological age does not accurately predict worse adverse postoperative complications in older hernia patients. Additionally, traditional risk screening calculators that rely heavily on age to risk stratify may not accurately capture a patient's true surgical risk. Surgeons should continue to explore nuanced patient risk assessments that more accurately capture age-related risk factors to better individualize perioperative risk.

Geriatric assessment and medical preoperative screening (GrAMPS) program for older hernia patients.

PURPOSE: The incidence of older adults undergoing inguinal and ventral hernia repairs is increasing. Older adults are disproportionately affected by age-related risk factors, which are often under-recognized and may adversely affect surgical outcomes. These age-related risk factors often termed "geriatric syndromes," include multimorbidity, frailty, cognitive impairment, depression, obesity, functional impairment, polypharmacy, and poor subjective health. The aim of this study was to identify the prevalence of age-related risk factors in older patients undergoing elective hernia repair. METHODS: Patients aged 60 years or older with a planned elective surgical repair of a ventral or inguinal hernia were prospectively enrolled in a clinic. Subjects completed several validated screening tools for geriatric syndromes. RESULTS: Seventy patients completed preoperative assessments (mean age: 68.5 years). In total, 24 (34.3%) screened positive for previously unrecognized objective cognitive impairment (Mini-Cog) and 33 (47.1%) for a subjective memory concern. Sixty patients (85.7%) met criteria for polypharmacy. Additionally, 48 (68.6%) screened positive for either pre-frailty (37, 52.9%) or frailty (11, 15.7%), and 66 (94.3%) had multimorbidity. Twenty-five (35.7%) patients self-rated their health as "poor" or "fair," and 18 (25.7%) patients endorsed some functional impairment. CONCLUSIONS: There is a high prevalence of age-related risk factors in older patients undergoing elective hernia repair. Further, these factors are often unrecognized and underappreciated despite their potential to significantly impact informed consent and shared decision making. Additional study is required to define the impact of these age-related risk factors on surgical outcomes, which will inform preoperative risk assessment and optimization through modifiable risk reduction.

Infection prevention plan to decrease surgical site infections in bariatric surgery patients.

BACKGROUND: Surgical site infections (SSI) are one of the most common complications of bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (QI) Program (MBSAQIP) allows accredited programs to develop processes for quality improvement based on data collection. The objective of this study was to decrease SSI rates in patients undergoing bariatric surgery at an accredited MBSAQIP center. METHODS: Using the MBSAQIP semiannual report, SSI rates were retrospectively reviewed. Baseline SSI rates were collected from 01/01/2014-12/31/2015. On 01/01/2016, the first infection prevention protocol (IPP-1) was created that included 4% chlorhexidine gluconate (CHG) showers, CHG wipes immediately prior to surgery, and routine cultures of SSIs. An updated IPP (IPP-2) was implemented on 09/01/2016, which discontinued routine surgical drain placement and broadened antibiotic coverage for penicillin allergic patients. RESULTS: During baseline data collection, SSI rates were 5.1%. After the implementation of IPP-1, SSI rates trended down to 2.5%. After implementation of IPP-2, SSI rates decreased significantly to 1.5%, a 66% relative risk reduction in SSIs from baseline. On multivariate regression analysis, the perioperative factors associated with an increased risk for SSIs included diabetes mellitus, intraoperative surgical drain placement, the number of hypertension medications prior to bariatric surgery, and an open approach. CONCLUSIONS: Our study demonstrates that the implementation of a specific protocol for reducing SSIs is safe and feasible in patients undergoing bariatric surgery. We also identified that the success of the IPP is likely centered on the elimination of routine drain placement during primary bariatric procedures.

Examination of abdominal wall perfusion using varying suture techniques for midline abdominal laparotomy closure.

BACKGROUND: With a growing interest in the primary prevention of incisional hernias, it has been hypothesized that different suturing techniques may cause various levels of tissue ischemia. Using ICG laser-induced fluorescence angiography (ICG-FA), we studied the effect of different suture materials and closure techniques on abdominal wall perfusion. METHODS: Fifteen porcine subjects underwent midline laparotomy, bilateral skin flap creation, and three separate 7 cm midline fascial incisions. Animals underwent fascial closure with 5 different techniques: (1) Running 0-PDS® II (polydioxanone) Suture with large bites; (2) Running 0-PDS II Suture with small bites; (3) Interrupted figure-of-eight (8) PDS II Suture, (4) Running 0-barbed STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Device large bite; (5) Running 0-STRATAFIX Symmetric PDS Plus Device small bites. ICG-FA signal intensity was recorded prior to fascial incision (baseline), immediately following fascial closure (closure), and at one-week (1-week.). Post-mortem, the abdominal walls were analyzed for inflammation, neovascularity, and necrosis. RESULTS: PDS II Suture with small bites, fascial closure at the caudal 1/3 of the abdominal wall, and the 1-week time period were all independently associated with increased tissue perfusion. There was also a significant increase in tissue perfusion from closure to 1-week when using small bites PDS II Suture compared to PDS II Suture figure-of-8 (p < 0.001) and a trend towards significance when compared with large bites PDS II Suture (p = 0.056). Additionally, the change in perfusion from baseline to 1 week with small bites was higher than with figure of 8 (p = 0.002). Across all locations, small bite PDS II Suture has greater total inflammation than figure of 8 (p < 0.001). CONCLUSIONS: The results suggest that the small bite technique increases abdominal wall perfusion and ICG-FA technology can reliably map abdominal wall perfusion. This finding may help explain the reduced incisional hernia rates seen in clinical studies with the small bite closure technique.

Chronological age does not predict postoperative outcomes following transversus abdominis release (TAR).

BACKGROUND: Transversus abdominis release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TAR is not a low risk operation, particularly in older adults who are disproportionately affected by multiple age-related risk factors. While past studies have suggested that age alone inconsistently predicts patient outcomes, data regarding age's effect on postoperative outcomes and wound complications following a TAR are lacking. METHODS: Patients who underwent either an open or robotic bilateral TAR from 1/2018 to 9/2020 were eligible for the study. Patients were stratified by age groups (≥ 60 years vs. < 60 years and < 60, 60-70, and ≥ 70) and by both age and operative approach. The rates of key postoperative outcomes and wound morbidity were compared between the various cohorts. RESULTS: A total of 300 patients were included: 165 patients were ≥ 60 and 135 patients were < 60. Cohorts stratified by age were well-matched for important hernia factors: defect size (p = 0.31), BMI ≥ 30 (p = 0.46), OR time (p = 0.25), percent open TAR (p = 0.42), diabetes (p = 0.45) and history of prior surgical site infection (p = 0.40). The older cohort had significantly higher rates of coronary artery disease, hypertension, and COPD. On univariate analysis, cohorts stratified by age had similar rates of key postoperative and wound complications including in-hospital complications (p = 0.62), length of stay (p = 0.47), readmissions (p = 0.66), and surgical site occurrences (p = 0.68). Additionally, cohorts stratified by both age and operative approach also had similar outcomes. Multivariate analysis showed that chronological age was not independently associated with surgical site occurrences (p = 0.22), readmissions (p = 0.99), in-hospital complications (p = 0.15), or severe complications (p = 0.79). CONCLUSION: Open and robotic TARs can be safely performed in older adults and chronological age alone is a poor predictor of patient morbidity following TAR. Further investigation of alternative preoperative screening tools that do not rely solely on age are needed to better optimize surgical outcomes in older adults following TAR.

Does immunosuppression increase perioperative wound morbidity in patients undergoing transversus abdominis release?

BACKGROUND: Transversus abdominis release is an effective procedure for complex ventral hernias. As wound complications contribute to hernia recurrences, mitigating risk factors is vitally important for hernia surgeons. Although immunosuppression can impair wound healing, it has inconsistently predicted wound occurrences, and its effect on wound morbidity after a transversus abdominis release is unknown. METHODS: Patients undergoing either an elective open or robotic bilateral transversus abdominis release with permanent synthetic mesh were retrospectively stratified by perioperative immunosuppression and secondarily by procedure type (open versus robotic) and immunosuppression. RESULTS: A total of 321 patients were included for analysis. Overall, 63 (19.6%) patients were on chronic immunosuppression, with history of solid-organ transplant being the most common indication (43 patients). Patients stratified by perioperative immunosuppression were well-matched with similar defect size (P = .97), body mass index ≥30 (P = .32), diabetes (P = .09), history of surgical site infection (P = .53), surgical approach (P = .53), and tobacco use history (P = .33). No differences between cohorts were elicited for any wound event when stratified by immunosuppression use. Similarly, no differences were elicited when cohorts were further stratified also by procedure type. CONCLUSION: Chronic immunosuppression is often viewed as a notable risk factor for wound occurrences after surgery. However, our data suggest immunosuppression may not significantly increase the risk of perioperative wound morbidity follow transversus abdominis release as previously predicted.

Transversus abdominis release with posterior component separation in patients with previously recurrent ventral hernias: A single institution experience.

BACKGROUND: Recurrent hernias pose significant challenges due to violated anatomic planes, resultant scar, and potential prior mesh. Transversus abdominis release has been widely utilized for complex hernias. Transversus abdominis release can provide a novel plane for dissection and mesh placement for recurrent hernias. This study provides our institution's experience with transversus abdominis release in patients with recurrent ventral hernias. METHODS: A retrospective chart review was conducted of patients with recurrent ventral hernias from January 2018 to September 2020 who underwent transversus abdominis release by 2 fellowship-trained abdominal wall surgeons. Combined procedures (ie, gynecological/urological), robotic totally extraperitoneal, and emergency cases were excluded. Demographics, perioperative, and postoperative outcomes were reviewed. RESULTS: In total, 108 patients underwent open-transversus abdominis release and 25 had robotic-transversus abdominis release for recurrent ventral hernias. All patients received a lightweight to midweight nonabsorbable polypropylene synthetic mesh. Mean age was 59, mean body mass index was 34 kg/m2, with mean hernia defect area of 333 cm2. We noted 34 (25.6%) surgical site occurrences and 11 (8.3%) surgical site infections. Mean postoperative follow-up was 15.5 months, with 7 (5%) recurrences (6 open-transversus abdominis release, 1 robotic-transversus abdominis release). A minimum 12-month follow-up was available for 62% of patients, and minimum 6-month follow-up in 80% of patients. CONCLUSION: Recurrent hernias pose significant operative challenges for surgeons due to violated tissue planes and limited repair options. Our experience suggests that transversus abdominis release may provide a durable repair for difficult recurrent ventral hernias. However, long-term postoperative follow-up over multiple years is still needed to establish extended durability of transversus abdominis release in these patients.

Systematic Review and Meta-Analysis of the Effectiveness of Insurance Requirements for Supervised Weight Loss Prior to Bariatric Surgery.

Many insurance plans impose strict criteria mandating preoperative weight loss attempts to limit patient's access to surgery. Preoperative acute weight loss has been hypothesized to reduce perioperative risk and to identify compliant patients who may have improved long-term weight loss. In this review, the evidence from studies examining clinical and weight loss outcomes both with and without preoperative weight loss are summarized. Although preoperative weight loss may have modest impact on some factors related to perioperative conduct, the evidence does not support these programs' effectiveness at promoting long-term weight loss. Provision of weight loss surgery should not be contingent on completion of insurance-mandated weight loss goals preoperatively, and these programs may, through patient attrition, actually do more harm than good.