Robotic Sugarbaker parastomal hernia repair: technique and outcomes.

PURPOSE: To present a novel technique for the repair of parastomal hernias. METHODS: A total of 15 patients underwent parastomal hernia repair. A robotic Sugarbaker technique was utilized for repair. The fascial defect was closed prior to robotic intraperitoneal placement of the mesh. Baseline demographics of the patients were obtained, and intra-operative and post-operative outcomes were tracked. RESULTS: The etiology of the ostomies was oncologic in all but three patients. Five of the stomas were urostomies (33.3%). Patient characteristics were as follows: age 64.9.1 ± 9.3 years, BMI 30.1 ± 4.7 kg/m2, smoking history 60.0%, and diabetes 6.7%. The mean size of the hernia defect was 46.0 ± 40.1 cm2 with a mesh size of 372.0 ± 101.2 cm2. The mean operative time was 182.0 ± 51.9 min. In seven patients, an inferolateral preperitoneal flap was created for mesh placement. Intraoperatively, only one enterotomy was made during dissection, which was repaired without complication. The mean length of stay was 4.2 ± 1.9 days. There was only one hernia recurrence (6.7%). There were no wound complications, surgical site infections, or mesh infections. A mean follow-up time of 14.2 ± 9.4 months was achieved. CONCLUSIONS: Robotic Sugarbaker parastomal hernia repair is a safe and effective technique. The results demonstrate the feasibility of fascial closure with this technique and a low recurrence rate. The authors propose this technique should be widely considered for parastomal hernia repair.

A systematic review of CT chest in COVID-19 diagnosis and its potential application in a surgical setting.

AIM: The aim of this work was to investigate the sensitivity and utility of CT of the chest in diagnosing active SARS-Cov-2 (COVID-19) infection, and its potential application to the surgical setting. METHOD: A literature review was conducted using Google Scholar® and MEDLINE®/PubMed® to identify current available evidence regarding the sensitivity of CT chest compared with RT-PCR for the diagnosis of COVID-19-positive patients. GRADE criteria and the QUADAS 2 tool were used to assess the level of evidence. RESULTS: A total of 20 articles were identified that addressed the question of sensitivity of CT for diagnosis of symptomatic and asymptomatic COVID-19-positive patients. Overall sensitivity of CT scan ranged from 57%-100% for symptomatic and 46%-100% for asymptomatic COVID-19 patients, while that of RT-PCR ranged from 39%-89%. CT chest was a better diagnostic modality and capable of detecting active infection earlier in the time course of infection than RT-PCR in symptomatic patients. In asymptomatic patients, disease prevalence seems to play a role in the positive predictive value. Minimal evidence exists regarding the sensitivity of CT in patients who are asymptomatic. CONCLUSIONS: In surgical patients, CT chest should be considered as an important adjunct for detection of COVID-19 infection in patients who are symptomatic with negative RT-PCR prior to any operation. For surgical patients who are asymptomatic, there is insufficient evidence to recommend routine preoperative CT chest for COVID-19 screening.

Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review.

BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection. METHODS: A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed. RESULTS: A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86). CONCLUSIONS: There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.

Triclosan-coated sutures and surgical site infection in abdominal surgery: the TRISTAN review, meta-analysis and trial sequential analysis.

INTRODUCTION: Surgical site infection (SSI) is a frequent complication of abdominal surgery causing increased morbidity. Triclosan-coated sutures are recommended to reduce SSI. The aim of this systematic review and meta-analysis was to evaluate the evidence from randomized controlled trials (RCT) comparing the rate of SSI in abdominal surgery when using triclosan-coated or uncoated sutures for fascial closure. METHODS: A systematic literature search was conducted using Medline, EMBASE, the Cochrane library, CINAHL, Scopus and Web of Science including publications until August 2017. The quality of the RCTs was evaluated using critical appraisal checklists from SIGN. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively. RESULTS: Eight RCTs on abdominal wall closure were included in the meta-analysis. In an overall comparison including both triclosan-coated Vicryl and PDS sutures for fascial closure, triclosan-coated sutures were superior in reducing the rate of SSI (OR 0.67; 0.46-0.98). When evaluating PDS sutures separately, there was no effect of triclosan-coating on the rate of SSI (OR 0.85; 0.61-1.17). Trial sequential analysis showed that the required information size (RIS) of 797 patients for triclosan-coated Vicryl sutures was almost reached with an accrued information size (AIS) of 795 patients. For triclosan-coated PDS sutures an AIS of 2707 patients was obtained, but the RIS was estimated to be 18,693 patients. CONCLUSION: Triclosan-coated Vicryl sutures for abdominal fascial closure decrease the risk of SSI significantly and based on the trial sequential analysis further RCTs will not change that outcome. There was no effect on SSI rate with the use of triclosan-coated PDS sutures for abdominal fascial closure, and it is unknown whether additional RCTs will change that.

[A woman with abdominal pain and absence of defaecation]. / Een vrouw met acute buikpijn en uitblijvende ontlasting.

A 62-years-old female presented to the Emergency Department with abdominal pain and absence of defaecation for two days. CT revealed an ileus with a change in the diameter of the small intestine and a segment without contrast in the intestinal wall. Laparotomy confirmed that a segment of the ileum was ischaemic.

Development of incisional herniation after midline laparotomy.

BACKGROUND: Incisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation. METHODS: This study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5 mm every 5 mm, or 1 cm every 1 cm) in patients scheduled to undergo elective abdominal surgery by midline laparotomy. The distance between the rectus abdominis muscles (RAM distance) was measured by standardized ultrasound imaging 1 month and 1 year after surgery. The relationship between the 1-year incidence of incisional hernia and the RAM distance at 1 month was investigated. RESULTS: Some 219 patients were investigated, 113 in the small-bites and 106 in the large-bites group. At 1 month after surgery the RAM distance was smaller for small bites than for large bites (mean(s.d.) 1·90(1·18) versus 2·39(1·34) cm respectively; P = 0·005). At 1 year, patients with incisional hernia had a longer RAM distance at 1 month than those with no incisional hernia (mean(s.d.) 2·43(1·48) versus 2·03(1·19) cm respectively; relative risk 1·14, 95 per cent c.i. 1·03 to 1·26, P = 0·015). CONCLUSION: A RAM distance greater than 2 cm at 1 month after midline laparotomy is associated with incisional hernia. Closure with small bites results in a smaller distance between the muscles.

Mesh expansion as the cause of bulging after abdominal wall hernia repair.

BACKGROUND: Recurrence is the most important complication of abdominal wall reconstruction. It is possible the repair itself is intact, but bulging or expansion of mesh causes recurrent swelling's of the abdominal wall. CASE SUMMARY: In this report, we present bulging of a polyester mesh due to central pore expansion. DISCUSSION: Repetitive stress and variations in intra-abdominal pressure can change tensile strength and stretches mesh materials. CONCLUSION: A swelling after abdominal wall repair can be caused by bulging of the mesh. A progressive bulging might be the result of failure of the mesh implant due to elongation. Mesh characteristics should be considered when choosing a feasible and suitable mesh for abdominal wall reconstruction. Clinical distinction between recurrent hernia and mesh bulging is difficult but therapeutically irrelevant in symptomatic patients.

European Hernia Society guidelines on the closure of abdominal wall incisions

BACKGROUND: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. METHODS: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. RESULTS: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. RECOMMENDATIONS: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.(AU)

European Hernia Society guidelines on the closure of abdominal wall incisions.

BACKGROUND: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. METHODS: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. RESULTS: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. RECOMMENDATIONS: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.

A systematic review of the surgical treatment of large incisional hernia.

PURPOSE: Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair. METHODS: A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model. RESULTS: Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of <3.6%, recurrence hazard <0.5% per year). Wound complications were frequent and most often seen after complex LIH repair. CONCLUSIONS: The use of mesh during LIH repair displayed the best recurrence rates and hazards. If possible mesh in sublay position should be used in cases of LIH repair.

In vitro model to study the biomaterial-dependent reaction of macrophages in an inflammatory environment.

BACKGROUND: Macrophages play an important role in the reaction to biomaterials, which sometimes have to be used in a surgical field at risk of contamination. The macrophage phenotype in reaction to biomaterials in an inflammatory environment was evaluated in both an in vivo and in vitro setting. METHODS: In the in vivo setting, polypropylene (PP) biomaterial was implanted for 28 days in the contaminated abdominal wall of rats, and upon removal analysed by routine histology as well as immunohistochemistry for CD68 (marker for macrophages), inducible nitric oxide synthase (iNOS - a marker for proinflammatory M1 macrophages) and CD206 (marker for anti-inflammatory M2 macrophages). For the in vitro model, human peripheral blood monocytes were cultured for 3 days on biomaterials made from PP, collagen (COL), polyethylene terephthalate (PET) and PET coated with collagen (PET+COL). These experiments were performed both with and without lipopolysaccharide and interferon γ stimulation. Secretion of both M1- and M2-related proteins was measured, and a relative M1/M2 index was calculated. RESULTS: In vivo, iNOS- and CD206-positive cells were found around the fibres of the implanted PP biomaterial. In vitro, macrophages on both PP and COL biomaterial had a relatively low M1/M2 index. Macrophages on the PET biomaterial had a high M1/M2 index, with the highest increase of M1 cytokines in an inflammatory environment. Macrophages on the PET+COL biomaterial also had a high M1/M2 index. CONCLUSION: Macrophages in an inflammatory environment in vitro still react in a biomaterial-dependent manner. This model can help to select biomaterials that are tolerated best in a surgical environment at risk of contamination.

Recommendations for reporting outcome results in abdominal wall repair: results of a Consensus meeting in Palermo, Italy, 28-30 June 2012.

BACKGROUND: The literature dealing with abdominal wall surgery is often flawed due to lack of adherence to accepted reporting standards and statistical methodology. MATERIALS AND METHODS: The EuraHS Working Group (European Registry of Abdominal Wall Hernias) organised a consensus meeting of surgical experts and researchers with an interest in abdominal wall surgery, including a statistician, the editors of the journal Hernia and scientists experienced in meta-analysis. Detailed discussions took place to identify the basic ground rules necessary to improve the quality of research reports related to abdominal wall reconstruction. RESULTS: A list of recommendations was formulated including more general issues on the scientific methodology and statistical approach. Standards and statements are available, each depending on the type of study that is being reported: the CONSORT statement for the Randomised Controlled Trials, the TREND statement for non randomised interventional studies, the STROBE statement for observational studies, the STARLITE statement for literature searches, the MOOSE statement for metaanalyses of observational studies and the PRISMA statement for systematic reviews and meta-analyses. A number of recommendations were made, including the use of previously published standard definitions and classifications relating to hernia variables and treatment; the use of the validated Clavien-Dindo classification to report complications in hernia surgery; the use of "time-to-event analysis" to report data on "freedom-of-recurrence" rather than the use of recurrence rates, because it is more sensitive and accounts for the patients that are lost to follow-up compared with other reporting methods. CONCLUSION: A set of recommendations for reporting outcome results of abdominal wall surgery was formulated as guidance for researchers. It is anticipated that the use of these recommendations will increase the quality and meaning of abdominal wall surgery research.

Biologic meshes are not superior to synthetic meshes in ventral hernia repair: an experimental study with long-term follow-up evaluation.

BACKGROUND: In laparoscopic incisional hernia repair, direct contact between the prosthesis and the abdominal viscera is inevitable, which may lead to an inflammatory reaction resulting in abdominal adhesion formation. This study compared five different synthetic and biologic meshes in terms of adhesion formation, shrinkage, incorporation, and histologic characteristics after a period of 30 and 90 days. METHODS: In 85 rats, a mesh was positioned intraperitoneally in direct contact with the viscera. Five different meshes were implanted: Prolene (polypropylene), Parietex composite (collagen-coated polyester), Strattice (porcine dermis, non-cross-linked), Surgisis (porcine small intestine submucosa, non-cross-linked), and Permacol (porcine dermis, cross-linked). The meshes were tested in terms of adhesion formation, shrinkage, and incorporation after a period of 30 and 90 days. Additionally, collagen formation after 90 days was determined. RESULTS: Significantly less adhesion formation was observed with Parietex composite (5 %; interquartile range [IQR], 2-5 %) and Strattice (5 %; IQR, 4-10 %) in the long term. In contrast, organs were attached to Permacol with four of seven meshes (57 %), and adhesion coverage of Surgisis mesh was present in 66 % (IQR, 0-100 %) of the cases. After 90 days, the best incorporation was seen with the Parietex composite mesh (79 %; IQR, 61-83 %). After 90 days, major alterations in adhesion formation were seen compared with 30 days. Histologically, Strattice and Parietex composite showed a new mesothelial layer on the visceral side of the mesh. Microscopic degradation and new collagen formation were seen in the Surgisis group. CONCLUSIONS: Parietex composite mesh demonstrated the best long-term results compared with all the other meshes. The biologic non-cross-linked mesh, Strattice, showed little adhesion formation and moderate shrinkage but poor incorporation. Biologic meshes are promising, but varying results require a more detailed investigation and demonstrate that biologic meshes are not necessarily superior to synthetic meshes. The significant changes that take place between 30 and 90 days should lead to careful interpretation of short-term experimental results.

Experimental study on synthetic and biological mesh implantation in a contaminated environment.

BACKGROUND: Implantation of meshes in a contaminated environment can be complicated by mesh infection and adhesion formation. METHODS: The caecal ligation and puncture model was used to induce peritonitis in 144 rats. Seven commercially available meshes were implanted intraperitoneally: six non-absorbable meshes, of which three had an absorbable coating, and one biological mesh. Mesh infection, intra-abdominal abscess formation, adhesion formation, incorporation and shrinkage were evaluated after 28 and 90 days. Histological examination with haematoxylin and eosin and picrosirius red staining was performed. RESULTS: No mesh infections occurred in Sepramesh(®) , Omyramesh(®) and Strattice(®) . One mesh infection occurred in Parietene(®) and Parietene Composite(®) . Significantly more mesh infections were found in C-Qur(®) (15 of 16; P ≤ 0·006) and Dualmesh(®) (7 of 15; P ≤ 0·035). Sepramesh(®) showed a significant increase in adhesion coverage from 12·5 per cent at 28 days to 60·0 per cent at 90 days (P = 0·010). At 90 days there was no significant difference between median adhesion coverage of Parietene Composite(®) (35·0 per cent), Omyramesh(®) (42·5 per cent), Sepramesh(®) (60·0 per cent) and Parietene(®) (72·5 per cent). After 90 days the adhesion coverage of Strattice(®) was 5·0 per cent, and incorporation (13·4 per cent) was significantly poorer than for other non-infected meshes (P ≤ 0·009). Dualmesh(®) showed shrinkage of 63 per cent after 90 days. CONCLUSION: Parietene Composite(®) and Omyramesh(®) performed well in a contaminated environment. Strattice(®) had little adhesion formation and no mesh infection, but poor incorporation. Some synthetic meshes can be as resistant to infection as biological meshes.

Postoperative adhesion prevention with a new barrier: an experimental study.

INTRODUCTION: Postoperative adhesion formation remains a major clinical problem. The aim of this study was to test the effect of a new hydrogel on adhesion formation in a rat model. MATERIALS AND METHODS: A reproducible rat model was used to induce standardized adhesion formation in three experiments. In experiment 1, a cross-linked polyvinyl alcohol (PVA) and carboxymethylcellulose (CMC) hydrogel (PVA/CMC, A-Part®; B. Braun Aesculap, Germany) was tested in different dosages. In experiment 2, PVA/CMC gel was compared to icodextrin 4% (Adept®; Baxter USA). In both groups, animals were sacrificed after 2 weeks. In experiment 3, histological examination after 4 and 6 weeks was performed. The percentage of adhesions to the defect was measured and the density was determined according to the Zühlke scale. During histological examination of the abdominal wall, the formation of neoperitoneum and potential residues of the agents were assessed. RESULTS: In experiment 1, a significant reduction in amount as well as density of the adhesions was visible with all dosages of PVA/CMC gel. In experiment 2, again quantity and density of the adhesions were diminished by PVA/CMC hydrogel compared to the control group. Icodextrin 4% showed no significant reduction in adhesion formation. In experiment 3, no residues of PVA/CMC gel or icodextrin 4% were found during histological examination after 4 and 6 weeks and neoperitoneum was present in all cases. CONCLUSION: PVA/CMC hydrogel appears to be a novel effective adhesion prevention agent. Together with an upcoming safety study, these data encourage to start clinical efficacy studies.