Lessons learnt from the construction and implementation of a prospective ventral hernia database.

PURPOSE: The New England VA Hernia Registry was created in 2011 to prospectively collect relevant details of ventral hernia repairs, with the intention to assess and improve long term outcomes. The goal of this study is to assess registry compliance. METHODS: All ventral hernia operations performed in five VA hospitals between 2011-2022 were obtained. We assessed compliance at the hospital and surgeon level. RESULTS: 3,516 cases were performed. Overall compliance with registry entry was 37.5%, ranging from 10.8% to 67.2% across hospitals. At the hospital level, there was a negative correlation between average yearly hernia volume per surgeon and registry compliance (r2 = 0.53). Surgeon compliance varied within hospitals and over time. CONCLUSION: Registry compliance was low and highly variable. Lack of interest, incentives, oversight, and surgeon turnover are possible factors for noncompliance. Building a registry with these factors in mind, providing timely feedback, and conducting frequent audits may improve compliance.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair.

BACKGROUND: Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. METHODS: A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. RESULTS: Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. CONCLUSION: Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

ANTECEDENTES: La nomenclatura de la inserción de una malla para la reparación de una hernia incisional ventral (ventral hernia, VH) es inconsistente y confusa. En la literatura indexada se usan varios términos, tales como 'inlay', 'sublay', y 'underlay' que pueden referirse a los mismos planos anatómicos. Este hecho frustra las comparaciones de técnicas quirúrgicas e invalida los metaanálisis que comparan resultados quirúrgicos en función del plano de inserción de la malla. En consecuencia, el objetivo de este estudio fue establecer una clasificación internacional de los planos de la pared abdominal (International Classification of Abdominal Wall Planes, ICAP). MÉTODOS: Se realizó un estudio Delphi, en el que participaron 20 cirujanos de pared abdominal reconocidos internacionalmente. Se identificaron diferentes términos que describían los planos de la pared abdominal anterior mediante la revisión de la literatura y el consenso de expertos. La lista inicial incluía 59 términos posibles. Los panelistas completaron un cuestionario que sugería una lista de opciones para los planos individuales de la pared abdominal. El consenso sobre un término fue predefinido cuando dicho término había sido seleccionado por ≥ 80% de panelistas. Se eliminaron los términos con una puntuación < 20%. RESULTADOS: La votación comenzó en agosto de 2018 y se completó en enero de 2019. Durante la Ronda 1, 43 (73%) términos fueron seleccionados por < 20% de los panelistas y se sugirieron 37 términos nuevos, dejando 53 términos para la Ronda 2. Cuatro planos alcanzaron un consenso en la Ronda 2 con los términos 'onlay', 'inlay', 'pre-peritoneal' e 'intra-peritoneal'. Treinta y cinco (66%) términos fueron seleccionados por < 20% de los panelistas y fueron eliminados. Después de la Ronda 3, se logró un consenso para 'anterectus' (ante-recto), 'interoblique' (inter-oblicuo), 'retrooblique' (retro-oblicuo) y 'retromuscular'. Se alcanzó un consenso por defecto para los planos 'retrorectus' (retro-recto) y 'transversalis fascial' (fascial transverso). CONCLUSIÓN: La ICAP ha sido desarrollada por el consenso de 20 cirujanos reconocidos internacionalmente. Su implementación debería mejorar la comunicación y la comparación entre cirujanos y estudios de investigación.

Validation of an electronic tool for flagging surgical site infections based on clinical practice patterns for triaging surveillance: Operational successes and barriers.

BACKGROUND: Surveillance is an effective strategy for reducing surgical site infections (SSIs); however, current identification methods are resource-intensive. Therefore, we sought to validate an electronic SSI triaging tool for detection of probable infections and identify operational barriers and challenges. METHODS: A retrospective cohort study was conducted among all Veterans Affairs Surgical Quality Improvement Program (VASQIP)-reviewed surgeries at 2 Veterans Affairs medical centers from October 1, 2011-September 30, 2014. During the postoperative period, clinical and administrative variables associated with SSI (relevant microbiology order, antibiotic order, radiology order, and administrative codes) were extracted from the electronic medical record and used to score the probability (high, intermediate, and low) that an SSI occurred. VASQIP manual chart review was used as the gold standard of comparison. RESULTS: VASQIP manual review identified 118 SSIs out of 3,700 surgeries (3.2%). There were 2,041, 1,428, and 231 surgeries that met criteria for low, intermediate, and high probability for SSI. The tool's area under the curve was 0.86 (95% confidence interval, 0.82-0.89). The sensitivity among low-probability surgeries was 92.4%, and the specificity among high-probability surgeries was 95.1%. CONCLUSIONS: The electronic SSI tool has the potential to be used for triaging VASQIP surveillance toward the high-probability surgeries and to avoid manual review of surgeries with low probability of SSI.

Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017

IMPORTANCE: The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. OBJECTIVE: To provide new and updated evidence-based recommendations for the prevention of SSI. EVIDENCE REVIEW: A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. FINDINGS: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. CONCLUSIONS AND RELEVANCE: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Evaluation of surgical outcomes of retro-rectus versus intraperitoneal reinforcement with bio-prosthetic mesh in the repair of contaminated ventral hernias.

INTRODUCTION: Hernia repairs in contaminated fields are often reinforced with a bioprosthetic mesh. When choosing which of the multiple musculofascial abdominal wall planes provides the most durable repair, there is little guidance. We hypothesized that the retro-rectus plane would reduce recurrence rates versus intraperitoneal placement due to greater surface area contact of mesh with well-vascularized tissue. METHODS: Forty-nine of the 80 patients in an ongoing, prospective, multicenter study of contaminated ventral hernia repairs (RICH study, NCT00617357) achieved fascial closure after musculofascial centralization and reinforcement with non-crosslinked porcine acellular dermal matrix (Strattice™, LifeCell, Branchburg, NJ) and were retrospectively analyzed. The Strattice was placed in the retro-rectus position in 23 patients and in the intraperitoneal position in 26. RESULTS: Subjects were comparable in age, obesity, prior wound infection, presence of a stoma, and infected mesh removal (p > 0.05). More smokers were present in the intraperitoneal group (p = 0.02). Retro-rectus defects were significantly wider and had larger area than the intraperitoneal repairs. At the 1-year follow-up, 44 (90%) of patients were available for review. There was no difference in wound infections, seromas, or hematomas. Recurrent hernias were identified in 10% of retro-rectus repairs and 30% of intraperitoneal repairs (p = 0.14). CONCLUSIONS: In this retrospective analysis of a prospective multicenter study of large, contaminated ventral hernias, despite a larger hernia defect in the retro-rectus group, placement of the mesh in the retro-rectus compartment resulted in a similar recurrence rate to intraperitoneal mesh placement. Ongoing evaluation is important to establish longer-term outcomes and the validity of these findings.

Classification and valuation of postoperative complications in a randomized trial of open versus laparoscopic ventral herniorrhaphy.

PURPOSE: Generic instruments used for the valuation of health states (e.g., EuroQol) often lack sensitivity to notable differences that are relevant to particular diseases or interventions. We developed a valuation methodology specifically for complications following ventral incisional herniorrhaphy (VIH). METHODS: Between 2004 and 2006, 146 patients were prospectively randomized to undergo laparoscopic (n = 73) or open (n = 73) VIH. The primary outcome of the trial was complications at 8 weeks. A three-step methodology was used to assign severity weights to complications. First, each complication was graded using the Clavien classification. Second, five reviewers were asked to independently and directly rate their perception of the severity of each class using a non-categorized visual analog scale. Zero represented an uncomplicated postoperative course, while 100 represented postoperative death. Third, the median, lowest, and highest values assigned to each class of complications were used to derive weighted complication scores for open and laparoscopic VIH. RESULTS: Open VIH had more complications than laparoscopic VIH (47.9 vs. 31.5%, respectively; P = 0.026). However, complications of laparoscopic VIH were more severe than those of open VIH. Non-parametric analysis revealed a statistically higher weighted complication score for open VIH (interquartile range: 0-20 for open vs. 0-10 for laparoscopic; P = 0.049). In the sensitivity analysis, similar results were obtained using the median, highest, and lowest weights. CONCLUSION: We describe a new methodology for the valuation of complications following VIH that allows a direct outcome comparison of procedures with different complication profiles. Further testing of the validity, reliability, and generalizability of this method is warranted.

Laparoscopic ventral hernia repair during the learning curve.

Large series of laparoscopic ventral hernia repair have shown excellent results. However, published comparative studies have had conflicting outcomes. We retrospectively reviewed the first 29 laparoscopic ventral hernia repairs performed at a VA Medical Center from January 2000 to June 2001. The outcome was compared to that of open repairs performed during the same time period. Outcomes between the groups were similar in all respects, except for the length of stay. The conversion rate for the laparoscopic approach was 13.8%. There was one death in the laparoscopic group due to an unrecognized enterotomy. There were three recurrences in the open group and one in the laparoscopic group with a mean follow up of 13 months. In our series, laparoscopic hernia repair resulted in a shorter hospital stay but no other significant benefits, along with a risk of missed enterotomy. The risk-benefit ratio for this procedure may be high during the learning curve.

Squamous cell carcinoma of the pancreas.

Squamous cell carcinoma of the pancreas is a controversial entity. Although some reports show that it is metastatic from another source, others demonstrate that it is a primary tumor. Between 1988 and 1997, fourteen cases of pancreatic squamous cell carcinoma were identified in the records of our pathology department. In seven instances the features were consistent with squamous cell carcinoma with no adenomatous component. The records of six of these patients were available for review and constitute the basis for this report. Five patients were diagnosed by means of percutaneous CT-guided fine-needle aspiration, whereas the sixth patient was diagnosed using a transduodenal core needle biopsy. At the time of diagnosis four patients had lung lesions, three patients had liver lesions, and two patients had lytic bone lesions. One patient had a 6 cm esophageal lesion. Surgical intervention had no impact on treatment or palliation in one of the patients. Chemotherapy and radiation therapy, alone or in combination, were ineffective in all patients. Median survival from the time of diagnosis was 2 months. We conclude that in cases of squamous cell carcinoma of the pancreas, every effort should be made to exclude adenomatous components histologically within the tumor and to exclude another primary source of squamous cell carcinoma. This will allow a better understanding of this entity and a refinement of therapy.

The value of orbital echography in orbital practice.

Twenty-three consecutive patients with orbital masses who were referred to a major medical center and later had biopsies underwent ophthalmic echographic evaluation. The efficacy of orbital echography was compared with both the clinical evaluation and other orbital imaging methods (computed tomography and magnetic resonance imaging). Echography was successful in all patients (100%) in detecting the orbital mass. The diagnosis was accurate in 18 of 22 patients (82%) echographically, 12 of 14 patients (86%) clinically, and 11 of 13 patients (85%) radiologically when a short differential was attempted. If all the patients examined were considered, echographic evaluation arrived at an accurate diagnosis in 18 of 23 patients (78%), clinical impression was accurate in 12 of 23 patients (52%), and radiologic evaluation was accurate in 11 of 20 patients (55%). In three patients, echography was the only imaging method used. The role of ophthalmic echography in the diagnosis of orbital masses is discussed.

Surgical myocardial revascularization.

In conclusion, surgical myocardial revascularization has utilized diverse methods to increase blood flow to the starving myocardium. These methods initially used the microcirculation as the portal to reach myocytes until angiography showed that the obstructions were macrovascular. This resulted in a 30-year era of direct attack on the coronary blockages by coronary bypass. Surgical conduits unfortunately have longevity considerably less than that of native arteries and are limited in number. Alternative conduits, both biologic and prosthetic, have not yet proved to have the same clinical results as the ITA. More patients are living long enough to have the extensiveness of their disease exhaust conventional therapies. Newer therapy, restricted thus far to untreatables, revisits the microcirculation by making laser channels. These many innovative procedures have benefited hundreds of thousands of patients. They emerged from the probity and innovation of many individual surgeons.

Preoperative cardiac evaluation is unnecessary in most patients undergoing vascular operations.

BACKGROUND: This study evaluated the impact of Goldman's index (GI), radionuclide ventriculography (RVG), and dipyridamole-thallium scintigraphy (DTS) on predicting cardiac outcome after vascular operations. METHODS: A total of 463 consecutive patients undergoing vascular operations were divided into those who had no DTS, those who had reversible ischemia by DTS, and those who had no reversible ischemia by DTS. GI, ejection fraction, wall motion abnormalities, rate of coronary angiography, and revascularization were determined for each group. RESULTS: Coronary revascularization was ultimately performed in 8% of patients with no DTS, 7% of patients with no ischemia by DTS, and 9% of patients with ischemia by DTS. The GI of 6.1 in patients who died postoperatively was significantly higher than the GI of 3.6 in patients who survived (P = 0.02). RVG did not predict mortality, morbidity, or need for coronary revascularization. CONCLUSION: Clinical assessment remains a good predictor for cardiac outcome in patients undergoing vascular operations. More extensive cardiac testing should be reserved for patients with higher GI and active cardiac problems.

Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation.

Gastric rupture is a rare complication of difficult airway management. In cases of vigorous mouth-to-mouth ventilation, bag-valve-mask ventilation, or esophageal intubation, gastric rupture and massive intraperitoneal free air may cause tension pneumoperitoneum. Hemodynamic instability necessitates immediate intervention, including needle decompression of the peritoneum followed by surgical exploration. We recently encountered two cases of gastric rupture with tension pneumoperitoneum that occurred after difficult endotracheal intubation. This report describes the presentation, treatment, and prevention of this entity.

Needle biopsy for suspicious lesions of the head of the pancreas: pitfalls and implications for therapy.

Controversy continues to exist concerning the optimal diagnostic approach to a pancreatic head lesion suspected of being a neoplasm. The objective of this study was to evaluate the impact of needle biopsy in suspicious pancreatic head neoplasia and its effect on therapy and outcome. Seventy-three patients with symptoms or signs of periampullary neoplasia and a pancreatic head lesion identified on CT scan were reviewed retrospectively. Forty patients with potentially resectable lesions underwent intraoperative transduodenal core needle biopsy of the head of the pancreas. Thirty-three patients underwent CT-guided percutaneous fine-needle aspiration. The sensitivity and specificity of core needle biopsy were 76% and 100%, respectively. One death was directly related to the procedure and therapy was adversely affected in one patient with a false negative result. The sensitivity and specificity of percutaneous fine-needle aspiration were 85% and 92%, respectively, and were not significantly different from the core needle biopsy results (P >0.3). Three false negative fine-needle aspiration biopsies occurred in patients with potentially resectable lesions and a low clinical suspicion for malignancy. In patients with a mass in the head of the pancreas on CT scan, fine-needle aspiration biopsy offers results similar to those of intraoperative transduodenal core needle biopsy. In patients estimated to have resectable disease, a pancreaticoduodenectomy should be performed without a biopsy. For patients with unresectable disease, cytologic examination of fine-needle aspirate should be performed. If this examination is positive, it offers the advantage of facilitating the construction of a rational plan for palliation.

Impact of a problem-based learning conference on surgery residents' in training exam (ABSITE) scores. American Board of Surgery in Training Exam.

The impact of problem-based learning on surgery residents' education is unknown. In this study we measured the impact of a weekly structured problem-based learning conference on surgery residents' ABSITE scores and compared it to traditional clinical conferences and self-studying. A questionnaire was designed to determine the perceived quality of the basic (PQCB), and the clinical (PQCC) conferences as well as self-studying (PQCS). The Pearson correlation between PQCB, PQCC, PQCS, and attendance at the basic science conference and each of the ABSITE total score (ABSITE), basic science (BS) and clinical science (CS) component scores were calculated. PQCS (4.2) was significantly higher than PQCB (2.9) and PQCC (2.5) (P = 0.0002). PQCS and PQCB correlated highly with each of ABSITE, CS, and BS while PQCc did not show any correlation. A high correlation was also observed between attendance at basic science and each of ABSITE, CS, and BS but narrowly missed significance. It was also observed that BS scores highly correlated to the CS scores at all postgraduate levels (P = 0.0001). We conclude that performance on all components of the ABSITE is mostly dependent on individual residents. This individual factor is boosted by self-studying which can be motivated by instituting a problem-based learning technique within the program. Traditional conferences even if popular among residents have no impact on measurement tests.

The challenge of therapy for pancreatitis-related common bile duct stricture.

BACKGROUND: Opinions regarding the appropriate clinical management of pancreatitis-related common bile duct (CBD) stricture vary considerably. PATIENTS AND METHODS: Nineteen patients with chronic pancreatitis and proven stricture of their CBD were included in this study. Their mean duct diameter was 16 mm, bilirubin was 8.4 mg/dL, and alkaline phosphatase was 784 mIU/mL. RESULTS: Five patients initially treated with endoscopic biliary stent placement are doing well at a mean follow-up of 7 months with only 1 patient requiring a biliary-enteric bypass. Four patients underwent a pancreaticoduodenectomy and the other 10 patients underwent a biliary-enteric bypass. Mean bilirubin and alkaline phosphatase at 13 months after therapy were 0.9 mg/dL and 144 mIU/mL. CONCLUSION: An endoscopically placed biliary stent will relieve obstruction due to the stricture for several months and allow the inflammatory process to follow its natural course. In patients with long-standing permanent biliary stricture, pancreatitis limited to the head of the pancreas, duodenal obstruction, or suspected pancreatic head carcinoma, pancreaticoduodenectomy is the operation of choice. Biliary-enteric bypass in association with gastric or pancreatic bypasses should be reserved for patients with severe inflammatory changes preventing a safe pancreaticoduodenectomy.

Delayed tension pneumopericardium after thoracotomy for penetrating chest trauma.

Tension pneumopericardium is a rare entity typically described in premature infants requiring positive-pressure ventilation. However, recent reports suggest an increase in its occurrence in adults. A case of delayed postoperative tension pneumopericardium in an adult patient is presented with a review of the history, pathophysiology, presentation, and treatment of this entity.

Emergency center arteriography in the evaluation of suspected peripheral vascular injuries in children.

During the 6-year period from 1983 to 1989, 109 children aged 3 to 18 years (mean, 16) with suspected peripheral vascular injuries underwent 113 emergency center arteriograms (ECA) performed by hand injection of contrast material using a single roentgenographic film. The most common indication for ECA was the proximity of the injury in 93 (82.3%) of the cases as penetrating injury accounted for 106 (94%) of the cases. There were 89 true-negative, 14 true-positive, 1 false-negative, and no false-positive arteriograms. The remaining 9 arteriograms were either equivocal or technically inadequate. The sensitivity, specificity, and diagnostic accuracy of this procedure were 98.9%, 100%, and 91.2%, respectively. Operative intervention was required for 9 (64.2%) injuries detected by emergency arteriography. The remaining 5 injuries were considered minor and were observed with no complications during a period of 21 months. Sixty-eight children (76.4%) with negative ECA were followed for a mean of 12 months with no vascular complications or growth abnormalities noted. ECA is a rapid, accurate, and cost-effective technique. It is of particular value in detecting the presence of occult arterial injuries that might have deleterious effects in the growing child.