Comparison of Medical Research Abstracts Written by Surgical Trainees and Senior Surgeons or Generated by Large Language Models.

Importance: Artificial intelligence (AI) has permeated academia, especially OpenAI Chat Generative Pretrained Transformer (ChatGPT), a large language model. However, little has been reported on its use in medical research. Objective: To assess a chatbot's capability to generate and grade medical research abstracts. Design, Setting, and Participants: In this cross-sectional study, ChatGPT versions 3.5 and 4.0 (referred to as chatbot 1 and chatbot 2) were coached to generate 10 abstracts by providing background literature, prompts, analyzed data for each topic, and 10 previously presented, unassociated abstracts to serve as models. The study was conducted between August 2023 and February 2024 (including data analysis). Exposure: Abstract versions utilizing the same topic and data were written by a surgical trainee or a senior physician or generated by chatbot 1 and chatbot 2 for comparison. The 10 training abstracts were written by 8 surgical residents or fellows, edited by the same senior surgeon, at a high-volume hospital in the Southeastern US with an emphasis on outcomes-based research. Abstract comparison was then based on 10 abstracts written by 5 surgical trainees within the first 6 months of their research year, edited by the same senior author. Main Outcomes and Measures: The primary outcome measurements were the abstract grades using 10- and 20-point scales and ranks (first to fourth). Abstract versions by chatbot 1, chatbot 2, junior residents, and the senior author were compared and judged by blinded surgeon-reviewers as well as both chatbot models. Five academic attending surgeons from Denmark, the UK, and the US, with extensive experience in surgical organizations, research, and abstract evaluation served as reviewers. Results: Surgeon-reviewers were unable to differentiate between abstract versions. Each reviewer ranked an AI-generated version first at least once. Abstracts demonstrated no difference in their median (IQR) 10-point scores (resident, 7.0 [6.0-8.0]; senior author, 7.0 [6.0-8.0]; chatbot 1, 7.0 [6.0-8.0]; chatbot 2, 7.0 [6.0-8.0]; P = .61), 20-point scores (resident, 14.0 [12.0-7.0]; senior author, 15.0 [13.0-17.0]; chatbot 1, 14.0 [12.0-16.0]; chatbot 2, 14.0 [13.0-16.0]; P = .50), or rank (resident, 3.0 [1.0-4.0]; senior author, 2.0 [1.0-4.0]; chatbot 1, 3.0 [2.0-4.0]; chatbot 2, 2.0 [1.0-3.0]; P = .14). The abstract grades given by chatbot 1 were comparable to the surgeon-reviewers' grades. However, chatbot 2 graded more favorably than the surgeon-reviewers and chatbot 1. Median (IQR) chatbot 2-reviewer grades were higher than surgeon-reviewer grades of all 4 abstract versions (resident, 14.0 [12.0-17.0] vs 16.9 [16.0-17.5]; P = .02; senior author, 15.0 [13.0-17.0] vs 17.0 [16.5-18.0]; P = .03; chatbot 1, 14.0 [12.0-16.0] vs 17.8 [17.5-18.5]; P = .002; chatbot 2, 14.0 [13.0-16.0] vs 16.8 [14.5-18.0]; P = .04). When comparing the grades of the 2 chatbots, chatbot 2 gave higher median (IQR) grades for abstracts than chatbot 1 (resident, 14.0 [13.0-15.0] vs 16.9 [16.0-17.5]; P = .003; senior author, 13.5 [13.0-15.5] vs 17.0 [16.5-18.0]; P = .004; chatbot 1, 14.5 [13.0-15.0] vs 17.8 [17.5-18.5]; P = .003; chatbot 2, 14.0 [13.0-15.0] vs 16.8 [14.5-18.0]; P = .01). Conclusions and Relevance: In this cross-sectional study, trained chatbots generated convincing medical abstracts, undifferentiable from resident or senior author drafts. Chatbot 1 graded abstracts similarly to surgeon-reviewers, while chatbot 2 was less stringent. These findings may assist surgeon-scientists in successfully implementing AI in medical research.

The carolinas crossover, a preperitoneal crossover for enhanced-view totally extraperitoneal (eTEP) ventral hernia repair (VHR): a novel technique.

PURPOSE: To present a novel technique of preperitoneal cross-over for eTEP VHR. METHODS: Patients who underwent robotic eTEP with mesh utilizing a preperitoneal cross over technique were identified using a single-institution hernia database. This novel technique involves minimally invasive access to the retro-rectus space on one side with midline cross over into the preperitoneal space on the contralateral side. Baseline demographics of the patients were obtained, and intra-operative and post-operative outcomes were reported. RESULTS: Nine VHR patients underwent robotic eTEP with mesh using a preperitoneal crossover technique. Five patients were male, mean age was 53 ± 18.4 years, and mean BMI was 32.5 ± 4.2 kg/m2. Two patients were diabetic and 2 were previous smokers. Two of the hernias were recurrent. The average hernia defect was 96.9 ± 45.5 cm2 and the average mesh size was 593.3 ± 168.2 cm2. Four patients underwent a unilateral TAR, while five patients did not require any component separation. All cases were CDC Class 1 wounds. All patients met discharge criteria on post-operative day 1. There was one post-operative wound occurrence which was a seroma. There were no infectious complications and no hernia recurrences. The average follow up was 1.4 ± 1.2 months. CONCLUSIONS: Preperitoneal cross-over during eTEP ventral hernia technique is a safe technique that allows placement of a large extra-peritoneal mesh. Early patient outcomes are favorable. Larger sample size and follow-up are needed to truly assess postoperative outcomes.

The benefits of preoperative smoking cessation on abdominal wall reconstruction outcomes: An examination of abstinent versus never smokers.

INTRODUCTION: Active smoking is related to wound and respiratory complications following abdominal wall reconstruction (AWR), but no AWR studies directly compare outcomes of abstinent-smokers (AS), fulfilling four-weeks of smoking cessation, to non-smokers (NS). METHODS: Prospectively maintained institutional database was queried for all AWR between 2012 and 2019. AS and NS were included. Primary outcomes were wound and respiratory complications; secondary outcome was recurrence. Standard statistical analyses were performed. RESULTS: Evaluation included 1088 patients, 305 AS and 783 NS. AS had a lower BMI (31.3 vs 32.7 â€‹kg/m2; P â€‹= â€‹0.004) but increased ASA Class III (51.5% vs 34.5 â€‹%, P â€‹= â€‹0.009), COPD (8.9% vs 4.0 â€‹%, P â€‹= â€‹0.001), comorbidities (6.3 vs 4.7, P < 0.001), and wound class (Class III/IV: 25.3% vs 15.8 â€‹%, P â€‹= â€‹0.003). AS had increased defect size (229 vs 209.1 â€‹cm2; P â€‹= â€‹0.023), use of component separation (CST) (52.5% vs 43.8 â€‹%; P â€‹= â€‹0.010) and hospital stay (6.6 vs 6.2 days, P â€‹= â€‹0.015). Postoperative wound, mesh, and pulmonary infection, respiratory failure, and recurrence were similar. On multivariable regression, wound class and complications predicted recurrence. BMI, panniculectomy and CST predicted wound complications. BMI, CST, and wound class predicted respiratory complications. CONCLUSION: Despite greater patient and hernia complexity, smoking cessation appears to result in similar outcomes to never-smokers in this AWR population.

Deep learning model utilizing clinical data alone outperforms image-based model for hernia recurrence following abdominal wall reconstruction with long-term follow up.

BACKGROUND: Deep learning models (DLMs) using preoperative computed tomography (CT) imaging have shown promise in predicting outcomes following abdominal wall reconstruction (AWR), including component separation, wound complications, and pulmonary failure. This study aimed to apply these methods in predicting hernia recurrence and to evaluate if incorporating additional clinical data would improve the DLM's predictive ability. METHODS: Patients were identified from a prospectively maintained single-institution database. Those who underwent AWR with available preoperative CTs were included, and those with < 18 months of follow up were excluded. Patients were separated into a training (80%) set and a testing (20%) set. A DLM was trained on the images only, and another DLM was trained on demographics only: age, sex, BMI, diabetes, and history of tobacco use. A mixed-value DLM incorporated data from both. The DLMs were evaluated by the area under the curve (AUC) in predicting recurrence. RESULTS: The models evaluated data from 190 AWR patients with a 14.7% recurrence rate after an average follow up of more than 7 years (mean ± SD: 86 ± 39 months; median [Q1, Q3]: 85.4 [56.1, 113.1]). Patients had a mean age of 57.5 ± 12.3 years and were majority (65.8%) female with a BMI of 34.2 ± 7.9 kg/m2. There were 28.9% with diabetes and 16.8% with a history of tobacco use. The AUCs for the imaging DLM, clinical DLM, and combined DLM were 0.500, 0.667, and 0.604, respectively. CONCLUSIONS: The clinical-only DLM outperformed both the image-only DLM and the mixed-value DLM in predicting recurrence. While all three models were poorly predictive of recurrence, the clinical-only DLM was the most predictive. These findings may indicate that imaging characteristics are not as useful for predicting recurrence as they have been for other AWR outcomes. Further research should focus on understanding the imaging characteristics that are identified by these DLMs and expanding the demographic information incorporated in the clinical-only DLM to further enhance the predictive ability of this model.

Machine learning, deep learning and hernia surgery. Are we pushing the limits of abdominal core health? A qualitative systematic review.

INTRODUCTION: This systematic review aims to evaluate the use of machine learning and artificial intelligence in hernia surgery. METHODS: The PRISMA guidelines were followed throughout this systematic review. The ROBINS-I and Rob 2 tools were used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study design, risk of bias, publication bias, and statistical analysis. RESULTS: A total of 13 articles were ultimately included for this review, describing the use of machine learning and deep learning for hernia surgery. All studies were published from 2020 to 2023. Articles varied regarding the population studied, type of machine learning or Deep Learning Model (DLM) used, and hernia type. Of the thirteen included studies, all included either inguinal, ventral, or incisional hernias. Four studies evaluated recognition of surgical steps during inguinal hernia repair videos. Two studies predicted outcomes using image-based DMLs. Seven studies developed and validated deep learning algorithms to predict outcomes and identify factors associated with postoperative complications. CONCLUSION: The use of ML for abdominal wall reconstruction has been shown to be a promising tool for predicting outcomes and identifying factors that could lead to postoperative complications.

Open repair of flank and lumbar hernias: 142 consecutive repairs at a high-volume hernia center.

BACKGROUND: Flank and lumbar hernias (FLH) are challenging to repair. This study aimed to establish a reproducible management strategy and analyze elective flank and lumbar repair (FLHR) outcomes from a single institution. METHODS: A prospective analysis using a hernia-specific database was performed examining patients undergoing open FLHR between 2004 and 2021. Variables included patient demographics and operative characteristics. RESULTS: Of 142 patients, 106 presented with flank hernias, and 36 with lumbar hernias. Patients, primarily ASA Class 2 or 3, exhibited a mean age of 57.0 â€‹± â€‹13.4 years and BMI of 30.2 â€‹± â€‹5.7 â€‹kg/m2. Repairs predominantly utilized synthetic mesh in the preperitoneal space (95.1 â€‹%). After 29.9 â€‹± â€‹13.1 months follow-up, wound infections occurred in 8.3 â€‹%; hernia recurrence was 3.5 â€‹%. At 6 months postoperatively, 21.2 â€‹% of patients reported chronic pain with two-thirds of these individuals having preoperative pain. CONCLUSIONS: Open preperitoneal FLHR provides a durable repair with low complication and hernia recurrence rates over 2.5 years of follow-up.

The Utilization of Laparoscopic Ventral Hernia Repair (LVHR) in Incarcerated and Strangulated Cases: A National Trend in Outcomes.

INTRODUCTION: Early after its adoption, minimally invasive surgery had limited usefulness in emergent cases. However, with improvements in equipment, techniques, and skills, laparoscopy in complex and emergency operations expanded substantially. This study aimed to examine the trend of laparoscopy in incarcerated or strangulated ventral hernia repair (VHR) over time. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for laparoscopic repair of incarcerated and strangulated hernias (LIS-VHR) and compared over 2 time periods, 2014-2016 and 2017-2019. RESULTS: The utilization of laparoscopy in all incarcerated or strangulated VHR increased over time (2014-2016: 39.9% (n = 14 075) vs 2017-2019: 46.3% (n = 18 369), P < .001). Though likely not clinically significant, demographics and comorbidities statistically differed between groups (female: 51.7% vs 50.0%, P = .003; age 54.5 ± 13.7 vs 55.4 ± 13.8 years, P < .001; BMI 34.9 ± 8.0 vs 34.6 ± 7.8 kg/m2, P < .001). Patients from 2017 to 2019 were less comorbid (18.9% vs 16.8% smokers, P < .001; 18.2% vs 17.3% diabetic, P = .036; 4.6% vs 4.1% COPD, P = .021) but had higher ASA classification (III: 43.3% vs 45.7%; IV: 2.5% vs 2.7%, P < .001). Hernia types (primary, incisional, recurrent) were similar in each group. Operative time (89.7 ± 59.3 vs 97.4 ± 63.4 min, P < .001) became longer but length-of-stay (1.4 ± 3.3 vs 1.1 ± 2.6 days, P < .001) decreased. There was no statistical difference in surgical complications, medical complications, reoperation, or readmission rates between periods. CONCLUSION: Laparoscopic VHR has become a routine method for treating incarcerated and strangulated hernias, and its utilization continues to increase over time. Clinical outcomes have remained the same while hospital stays have decreased.

Factors Associated With Respiratory Failure After Open Ventral Hernia Repair: An Evaluation of the NSQIP Database.

An analysis of ACS-NSQIP open ventral hernia repair (OVHR) data (2017-2019) was performed. Respiratory failure (RF) occurred in 643 patients (1%) and not in 63,213 (99%) (nRF). Respiratory failure patients were older (63.7 vs 57 years, P < .001) and more comorbid: insulin-dependent diabetes (14.7% vs 5.8%, P < .001), COPD (19.4% vs 5.2%, P < .001), BMI (36.0 vs 32.8, P < .001), and current tobacco use (24.9% vs 17.6%, P < .001). Respiratory failure patients had greater ASA scores (ASA 3: 63.3% vs 47.8%, P < .001), bowel resection (8.2% vs 1.3%, P < .001), component separation (20.1% vs 9.0%, P < .001), operative times (178.4 vs 98.8 minutes, P < .001), complications (deep wound infections 3.6% vs 1.0%, organ space infections 13.2% vs 1.0%, wound dehiscence 3.1% vs 0.6%, acute renal failure 11.7% vs 0.1%), and hospital stay (13.7 vs 2.3 days), with fewer home discharges (44.3% vs 96.4%) (all P < .001). Respiratory failure patients had higher mortality compared to nRF (20.2% vs 0.1%, P < .001). Respiratory failure after OVHR is rare but correlates closely with significant wound, systemic, and social complications. Preoperative management of risk factors would be appropriate in high-risk patients.

Missing the Mark: Evaluating the Validity of the Ventral Hernia Screen in Detecting Recurrence.

PURPOSE: Hernia recurrence is a primary metric in evaluating the success of ventral hernia repair (VHR). Current screening methods for hernia recurrence, including the validated Ventral Hernia Screening (VHS) questionnaire, have not yet been critically evaluated. The purpose of this study was to evaluate the predictive value of the VHS for hernia recurrence. METHODS: This is a retrospective cohort study of adult patients who underwent primary VHR utilizing poly-4-hydroxybutyrate mesh at a single-institution from January 2016 to December 2021 who completed at least one VHS during their postoperative follow-up. All patients who screened positive underwent follow-up diagnostic computed tomography or physical examination for confirmation of hernia recurrence. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed for each item and the VHS as a whole. RESULTS: A total of 68 patients who completed 119 VHS questionnaires were included. The median time to VHS administration was 3.6 years (range .8-6.3 years). The VHS tool had a sensitivity of 40.0%, specificity of 71.1%, PPV of 5.7%, and NPV of 96.4%. Individual items of the VHS also produced poor screening effects, with sensitivities between 20 and 40%, specificities between 79 and 97%, PPVs between 4 and 25%, and NPVs from 95 to 97%. CONCLUSION: The VHS was a poor positive predictive tool for hernia recurrence, with both a low PPV and sensitivity. Many patients may be unaware of when they truly have hernia recurrence in the long term. More rigorous tools need to be developed to monitor recurrence following VHR.

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice.

BACKGROUND: Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability. METHODS: A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test. RESULTS: There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001). CONCLUSION: The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

Fragility of Randomized Clinical Trials Using Mesh in Abdominal Wall Reconstruction.

This systematic review evaluates the fragility of randomized clinical trials that used mesh in abdominal wall reconstruction.

Early warning: End-tidal carbon dioxide is associated with central venous oxygenation under continuous cardiorespiratory monitoring in a porcine model of hemorrhagic shock and resuscitation.

BACKGROUND: End-tidal carbon dioxide (ETCO2) has previously shown promise as a predictor of shock severity and mortality in trauma. ETCO2 monitoring is non-invasive, real-time, and readily available in prehospital settings, but the temporal relationship of ETCO2 to systemic oxygen transport has not been thoroughly investigated in the context of hemorrhagic shock. METHODS: A validated porcine model of hemorrhagic shock and resuscitation was used in male Yorkshire swine (N â€‹= â€‹7). Both ETCO2 and central venous oxygenation (SCVO2) were monitored and recorded continuously in addition to other traditional hemodynamic variables. RESULTS: Linear regression analysis showed that ETCO2 was associated with ScvO2 both throughout the experiment (ߠ​= â€‹1.783, 95% confidence interval (CI) [1.552-2.014], p â€‹< â€‹0.001) and during the period of most rapid hemorrhage (ߠ​= â€‹4.896, 95% CI [2.416-7.377], p â€‹< â€‹0.001) when there was a marked decrease in ETCO2. CONCLUSIONS: ETCO2 and ScvO2 were closely associated during rapid hemorrhage and continued to be temporally associated throughout shock and resuscitation.

Defining surgical risk in octogenarians undergoing paraesophageal hernia repair.

BACKGROUND: With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR). METHODS: The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed. RESULTS: From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001). CONCLUSIONS: Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis.

Prospective, international analysis of quality of life outcomes in recurrent versus primary ventral hernia repairs.

BACKGROUND: Quality of life (QOL) has become a key outcome measure following ventral hernia repair (VHR), but recurrent and primary VHR have not been compared in this context previously. METHODS: The International Hernia Mesh Registry (2008-2019) was used to identify patients with QOL data scored by the Carolinas Comfort Scale preoperatively and postoperatively at 1 year. RESULTS: Repairs were performed in 227 recurrent and 1,122 primary VHs. Recurrent patients had a higher BMI, larger defects, and were more likely to have preoperative pain, but other comorbidities were equal. Recurrence rates at 1 year were equivalent. Recurrent patients had a greater improvement in pain (-6.3 ± 10.2 vs -4.3 ± 8.3,p = 0.002) and movement limitation (-5.5 ± 10.0 vs -3.2 ± 7.2,p < 0.001) compared to primary patients, but they had increased postoperative mesh sensation (4.6 ± 7.7 vs 2.7 ± 5.5,p < 0.001). CONCLUSIONS: Recurrent VHRs led to improved pain and movement limitation, but increased mesh sensation. These findings may be useful for preoperative counseling in the elective setting.

The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis.

INTRODUCTION: Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes. METHODS: The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients. RESULTS: In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m2 (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036). CONCLUSION: Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.

Preservation of deep epigastric perforators during anterior component separation technique (ACST) results in equivalent wound complications compared to transversus abdominis release (TAR).

PURPOSE: The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction(AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between perforator sparing anterior component separation(PS-ACST) and transversus abdominus release(TAR). METHODS: Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015 to 2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed. RESULTS: A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p = 0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p < 0.001). The PS-ACST group had a larger hernia defect size (375.2 ± 156.7 vs 234.4 ± 126.9cm2, p < 0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p < 0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p = 0.129) nor was the mesh infection rate (0% vs 1.6%, p = 0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p > 0.05). CONCLUSION: PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications.

State-of-the-art abdominal wall reconstruction and closure.

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds. METHODS: A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both. RESULTS: In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm2 vs. 208 ± 155cm2; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection. CONCLUSIONS: Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

Impact of race and ethnicity on rates of emergent ventral hernia repair (VHR): has anything changed?

BACKGROUND: Non-white patients have been shown to have higher rates of emergent VHR, though no study to date has characterized these disparities over time. METHODS: National Surgical Quality Improvement Program (NSQIP) database was queried for VHR patients between 2008 and 2019. White, black, and hispanic patients were included for analysis. Older (2008-2011) versus New (2016-2019) time-periods were compared. The primary outcome was emergent VHR proportion. Multivariable analysis identified predictors of emergent VHR, then patients in each time-period were propensity matched (PSM) to control for confounders. RESULTS: The 665,809 VHRs between 2008 and 2019 consisted of 69.2% white, 9.7% black, and 8.1% hispanic patients. Emergent VHR rates were higher (all p < 0.001) for black (6.8%) and hispanic (5.6%) patients compared to White (4.1%). Emergent VHR rates between white vs black and white vs hispanic for both old (4.6% vs 7.4% and 4.6% vs 7.4%) and new (3.6% vs 5.8% and 3.6% vs 5.1%) groups demonstrated lower rates in White patients (all p < 0.001). Ratios of emergent VHR rates over time (old to new) remained similar (black:white 1.61-1.61; hispanic:white 1.43-1.42). Multivariable analysis showed older age, higher BMI, smoking, female sex, and increasing ASA class increased odds for emergent VHR. Comparison of PSM-groups (white-PSM vs black-PSM and white-PSM vs hispanic-PSM) for both old (5.0% vs 7.0% and 3.6% vs 6.3%) and new (3.2% vs 4.8% and 3.8% vs 5.5%) time-periods showed lower emergent VHR rates in white patients (all p < 0.001). Ratios of emergent VHR rates over time increased for black patients and decreased for Hispanic patients (black:white:1.4 to 1.5, and hispanic:white:1.75 to 1.45). CONCLUSION: Black and Hispanic patients have higher rates of emergent VHR compared to White patients, and this has not improved over time. After PSM to control for confounding variables, disparities in emergent VHR rates have increased for Black patients and decreased for Hispanic patients.