Hidden hernias hurt: a plea for early diagnosis and treatment of occult inguinal hernias.

INTRODUCTION: Hidden or occult inguinal hernias are symptomatic hernias that do not present with a bulge. For some surgeons, if a bulge is not present, then no hernia repair is contemplated. We report preoperative findings of patients with occult inguinal hernias and outcomes after repair to assist in early detection and treatment of this special population. METHODS: All patients who underwent inguinal hernia repairs, 2008-2019, were reviewed. Patients were classified as having occult inguinal hernias if they (a) complained of groin pain, (b) did not have bulging on exam, (c) had supportive imaging showing an inguinal hernia, and (d) were confirmed to have inguinal hernias that were repaired intraoperatively. Presentation and outcomes were compared with the non-occult group treated during the same time period. RESULTS: Of 485 patients who underwent elective inguinal hernia repairs over 10 years, 212 (44%) had occult inguinal hernias. Patients in the occult group were significantly more likely to be female, younger, and with higher BMI compared to the non-occult group. They also had more preoperative pain for a significantly longer time. This was associated with higher incidence of pain medications usage, including opioids, in the occult group. On physical examination, those with occult hernias were twice as likely to have tenderness over the inguinal canal. Most hernia repairs (66%) were laparoscopic and 94% used mesh. Postoperatively, the occult group had 83% resolution of symptoms after hernia repair. CONCLUSION: Some surgeons hesitate recommending hernia repair to patients with occult inguinal hernias, as these patients do not fit the traditional definition of a hernia, i.e., a bulge. Our study challenges this perception by showing that discounting groin pain due to occult hernia prolongs patient's suffering and may risk increased opioid use, especially in females, although 83% cure can be achieved with hernia repair.

Impact of patient's sex on groin hernia repair: A systematic review and meta-analysis.

BACKGROUND: Groin hernia repair (GHR) is a performed procedure worldwide, with approximately 20 million surgeries carried out each year. Despite being less common in females, there is a lack of research on how sex influences the outcomes of GHR. This systematic review and meta-analysis aim to assess how patient sex impacts results in GHR. METHODS: We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. We searched for studies up to October 2023 in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. The studies included focused on sex outcomes for both robotic and open GHR procedures. Data extraction and quality assessment were conducted using the Risk of Bias in Non-Randomized Studies - Of Interventions tool. Our statistical analysis was performed using the metafor package in RStudio. RESULTS: After screening a total of 3917 articles, we identified 29 studies that met our criteria, comprising a total of 1,236,694 patients. Among them, 98,641 (7.98%) patients were females. Our findings showed that females had higher rates of hernia recurrence (RR 1.28), chronic pain (RR 1.52), and surgical site infections (SSIs) (RR 1.46) compared to males. Females showed a lower tendency to undergo minimally invasive surgery (MIS) with a relative risk of 0.82 (95% CI 0.69-0.97; p = 0.02). CONCLUSION: Females tend to face higher rates of complications after GHR such as an elevated risk of chronic pain, recurrence, and surgical site infections (SSI). Moreover, they undergo fewer MIS options compared to males. These results underscore the importance of research to enhance outcomes for women undergoing GHR.

Sex-based differences in inguinal hernia factors.

BACKGROUND: Much of our knowledge about inguinal hernias is based on males. Meanwhile, it is established that women have worse outcomes after inguinal hernia repair, with more chronic pain and higher recurrences. Pediatric literature shows inguinal hernias in females are more likely to be bilateral, incarcerated, and carry a stronger genetic predisposition than males. We aimed to evaluate sex-based differences in inguinal hernia factors in adults, to help supplement the paucity of literature in the adult population. METHODS: An institutional database of patients undergoing repair of primary inguinal hernias was queried with focus on preoperative risk factors and operative characteristics. Multivariate analysis was performed looking for independent variables associated with a greater number of hernia defects found intraoperatively. RESULTS: Among 494 patients, 202 (40.9%) were female. Number of risk factors among females was significantly higher than males (1.53 vs 1.2, p = 0.003). Females had significantly more constipation, GERD, and asthma and lower BMI than males. Family history of hernias was similar between both sexes. As expected, females had significantly less direct hernias (12.9% vs 32.9%, p < 0.001) and more femoral hernias (38.5% vs 12.2%, p < 0.001) than males. Bilaterality was similar. Females undergoing inguinal hernia repair averaged 1.23 prior deliveries. Regression analysis showed age, sex, BMI, and number of deliveries were not correlated with the number of defects. CONCLUSIONS: Females undergoing primary inguinal hernia repair had more preoperative risk factors for inguinal hernia than males. In our population, there was no higher incidence of bilaterality or significant genetic predisposition in females as noted by family history of hernias. Age, sex, BMI and number of deliveries did not correlate with the number of hernia defects found. Our study promotes awareness of inguinal hernias in females and presents new data to quantify sex-based differences and predispositions to inguinal hernias.

Risks of therapeutic versus prophylactic neurectomies.

INTRODUCTION: Neuralgia due to a peripheral nerve injury may result in chronic pain, requiring a therapeutic surgical neurectomy. Meanwhile, some neurectomies are performed prophylactically, such as during inguinal mesh removal. Outcomes and risks associated with neurectomies are largely unknown despite consensus panels recommending them. METHODS: All patients who underwent neurectomy 2013-2020 were analyzed. Data collection included demographics, preoperative symptoms, and postoperative outcomes. Indications for neurectomy were categorized as "therapeutic" if the patient had preoperative neuralgia or "prophylactic" if neurectomy was deemed necessary intra-operatively. RESULTS: 66 patients underwent 80 operations and a total of 122 neurectomies. On average, 1.5 neurectomies were performed per operation. Therapeutic neurectomies were performed in 42 (64%) patients and prophylactic in 34 (52%). The most commonly transected nerve was the ilioinguinal nerve. Average preoperative pain score was 5.8/10. On paired analysis, there was a significant reduction in pain after prophylactic neurectomy (2.5 points, p = 0.002) but not after therapeutic neurectomy. None of the nerves transected prophylactically had postoperative neuralgia, whereas 35% of the nerves transected therapeutically resulted in persistent or recurrent neuralgia (p < 0.001). To treat this, 21% required only nerve blocks and 9% required ablation or reoperative neurectomy. Three patients had complex regional pain syndrome (CRPS), a severe complication; all three were diagnosed with chronic pain syndrome pre-operatively. DISCUSSION: We demonstrate that prophylactic neurectomy is largely safe. In contrast, a therapeutic neurectomy had a 35% risk of persistent or recurrent neuralgia, 9% required additional ablative or reoperative neurectomy. Three patients advanced from chronic pain syndrome to CRPS. We recommend the decision to perform a neurectomy be judicious and selective, especially in patients with known chronic pain syndrome. Prior to planning surgical neurectomy, other less invasive modalities should be exhausted and patients should be aware of its risks.

Outcomes from laparoscopic versus robotic mesh removal after inguinal hernia repair.

INTRODUCTION: Preperitoneally placed mesh for inguinal hernia repair may require removal to address hernia recurrence, mesh reaction, meshoma, or other chronic pain. These are best approached either laparoscopically or robotically, but there is no consensus on which is the best approach for mesh removal nor are there any studies to evaluate and compare their outcomes. METHODS: All patients who underwent inguinal mesh removal via laparoscopic and robotic approaches from 2011 to 2020 were analyzed. Data regarding demographics, preoperative, intraoperative, and postoperative outcomes were collected. RESULTS: Over 9 years, 62 patients underwent 24 laparoscopic and 50 robotic operations. Laparoscopic cases had a shorter operative time by a mean of 55 min (p = 0.02). There were no differences in intraoperative complications or postoperative outcomes between the two groups. Patients in both groups showed significant improvement after mesh removal (p = 0.02, p < 0.01) within 2 weeks postoperatively and at long-term follow up (p < 0.01, p < 0.01). CONCLUSION: It is our experience that both laparoscopic and robotic approaches are viable options for removal of retroperitoneally placed inguinal mesh. Operative time with the laparoscopic approach was significantly shorter than the robotic approach. Patients on average had significant reduction in their preoperative pain, regardless of the approach. Minimally invasive mesh removal is a technically challenging operation, with risk of vascular and nerve injuries regardless of the approach. These findings demonstrate that both modalities are safe and effective with experienced surgeons.

Flank incisional hernia after lateral approach spine operations: presentation and outcomes after repair.

BACKGROUND: The flank approach to lumbar spine surgery is considered a new minimally invasive alternative to the anterior abdominal approach. Flank incisional hernia is one complication, but it has been poorly studied. METHODS: Retrospective review of patients referred for evaluation of abdominal bulging after Lateral Interbody Fusion (LIF), 2013-2020. RESULTS: Seventeen patients were evaluated for abdominal bulging after LIF: 14 were diagnosed with incisional hernias. Three with denervation injury without hernia defect were excluded. CONCLUSIONS: This is the largest study addressing incisional flank hernias after LIF, an under-represented complication in the spine literature. We show that the patients present early, within months of their operation, and yet most hernias are not diagnosed for over a year. Although LIF is considered a minimally invasive procedure, the morbidity from hernia complications cannot be overlooked. These flank hernias are difficult to repair with suboptimal outcomes. We prefer robotic approach with primary closure of the defect and extraperitoneal sublay mesh, whenever possible. Prevention is key. To help reduce risk of hernia, we recommend closure of all muscle layers with slowly absorbable suture; this is different than was originally described in the spine literature.

SAGES white paper on the current state of community practice surgeons: re-discovering the value of our community practice surgeons.

BACKGROUND: The Community Practice (CP) surgeon is the first point of access to surgical care globally and performs the majority of procedures in the USA. CP surgeons include those of various practice models, locations and communities, education and training, and much more. It is a diverse group that drives quality, access to care, research, and innovation. The SAGES CP Committee was formed to better define the role and highlight the contribution of the CP surgeon, as well as advocate for the position of CP surgeons in our society. METHODS: In 2018, a survey was distributed to the SAGES membership asking members to self-identify as either a Community Surgeon or Academic Surgeon. RESULTS: The majority (71%) of SAGES members surveyed self-identified as "Community Surgeons." This was in stark contrast to the distribution of Community versus Academic Surgeons in SAGES leadership (25% versus 75%, respectively). CONCLUSION: By better defining the characteristics and role of the CP, SAGES will be better informed on how to effectively engage with this large group within the society and increase its representation within the leadership. The CP Committee met on a biannual basis over a period of two years focusing on assessing their role in the SAGES organization. The committee members created the following initial goals: (1) define in a broad sense the characteristics of a CP Surgeon, (2) discuss and characterize the value of the CP surgeons, (3) highlight past and future areas of contributions of the group, and (4) delineate ways to engage and represent this subgroup. This manuscript is a culmination of the work of this committee while also serving as a way to support the initiatives and direction of SAGES leadership.

Thou shalt not trust online videos for inguinal hernia repair techniques.

BACKGROUND: Videos are used by surgeons when learning new techniques; however, online videos are often not vetted. Our aim is to review online videos of laparoscopic inguinal hernia repairs based on a benchmark for critical view of the myopectineal orifice (MPO) and safe inguinal hernia repair as defined by Daes and Felix and commonly referred to as "the 9 Commandments." METHODS AND MATERIALS: YouTubeⓇ was queried for "laparoscopic inguinal hernia repair." The top 50 videos were ranked based on number of views. Those endorsed and/or vetted by surgical societies were excluded (n = 4). Three expert hernia surgeons scored the videos based on adherence to the 9 Commandments. RESULTS: The 50 videos originated from 11 countries. They had 72,825 mean views and a mean runtime of 14 min. Videos obeyed a median of 77.8% of commandments shown. Eight videos (16%) obeyed all 9 (100%) commandments. Three videos (6%) failed to obey any commandments. Operations employed TEP (18, 36%), TAPP (28, 56%), and rTAPP (4, 8%) approach. Stratification by approach showed significant variance in commandments obeyed (Kurskal-Wallis, p = 0.016) with significant difference between TEP and rTAPP scores (p = 0.008) and no significant difference between TEP and TAPP or rTAPP and TAPP scores. Twenty-three videos (46%) displayed unsafe techniques including: threatened critical structures (16, 32%), rough tissue handling (15, 30%), and dangerous placement of fixation (9, 18%). CONCLUSION: Online surgical videos on YouTube are not reliable in demonstrating best practices for minimally invasive inguinal hernia repairs. In our study, only 16% of the most viewed videos followed all 9 Commandments for critical view of the MPO. Many showed suboptimal repairs with significant safety concerns. While a significant number of online videos are a free and readily available resource for surgeons around the world, we recommend caution in relying on non-vetted videos as a form of surgical education.

Acronyms Use in Abdominal Wall Reconstruction: Introduction to a New Language.

BACKGROUND: The use of acronyms in medicine is widespread, aiming to simplify and condense communication. Online communication in social media platforms seems to enhance the use of acronyms, but their efficiency in message delivery may be negated by their abundance and unfamiliarity, causing more confusion than clarity. We analyzed the use of acronyms in a closed Facebook group dedicated to abdominal wall reconstruction (AWR), as the rapid recent development of this field has resulted in many new acronyms. Our aim was to classify the different acronyms and create a public reference. METHODS: The International Hernia Collaboration, a hernia-related Facebook group, now communicating more than 7500 surgeons from 99 countries, was studied, by extracting acronyms used since its inception in 2012. Acronyms were categorized and interpreted, to create a small dictionary comprised of several tables. RESULTS: Commonly used acronyms were identified, as well as commonly used prefixes that modify the acronyms' meaning. Tables were created, classifying acronyms by their subject: 1.Anatomy2.Diseases and clinical conditions3.Techniques and materials. CONCLUSION: The use of acronyms increased in social media-based communication. Aiming to simplify the language, the inflation of terms may have achieved the opposite, by adding a multitude of unfamiliar and confusing terms. We have created a public reference for AWR-related acronyms. Limiting the liberal creation of new acronyms is recommended, especially in a rapidly changing field as AWR.

Step-by-step guide to safe removal of pre-peritoneal inguinal mesh.

BACKGROUND: Inguinal hernia repairs are among the most common operations performed worldwide. An increasing number is performed minimally invasively with mesh placed pre-peritoneally. Some situations may require mesh removal. This can be complex and challenging. We share our technique to remove pre-peritoneal mesh using a minimally invasive approach. METHODS: The multiple steps involved in robotic-assisted pre-peritoneal mesh removal are reviewed in detail, including preoperative planning, intraoperative positioning, review of anatomic landmarks, and systematic approach with technical tips to reduce complications. RESULTS: We provide an attached narrated video guide with a written summary to outline pre-peritoneal inguinal mesh removal. The steps are applicable to both robotic-assisted and laparoscopic approaches. We present a video of the robotic-assisted approach. We prefer the robotic-assisted approach for most pre-peritoneal mesh removal based on results of our retrospective series of 26 patients undergoing 31 mesh removals. We noted that our robotic-assisted approach was more effective than the laparoscopic approach, with significantly less incidence of vascular injury (0 vs 5, p < 0.05) and less nerve (1 vs 4) and spermatic cord injuries (0 vs 1). CONCLUSIONS: As pre-peritoneal inguinal mesh implantation becomes more popular, surgeons may be seeing more patients with complications who may require mesh removal. We provide a detailed step-by-step approach with video to serve as a guide to surgeons who are planning for safe removal of pre-peritoneal inguinal hernia mesh.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

OBJECTIVE: To achieve consensus on the best practices in the management of ventral hernias (VH). BACKGROUND: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. METHODS: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. RESULTS: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. CONCLUSIONS: Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

An anti-inflammatory bundle may help avoid opioids for low-risk outpatient procedures.

BACKGROUND: Currently, over half of drug overdose deaths are due to opioids. Opioid alternatives may be prescribed to help curb the opioid epidemic. However, little is known about their efficacy for acute postoperative pain. METHODS: We studied patients who underwent low-risk outpatient surgery. Perioperatively, all patients were started on an anti-inflammatory bundle consisting of multimodal pain remedies. Opioids were available to the patients postoperatively. Pain scores and opioid use were recorded. RESULTS: Over 18 months, 120 patients underwent low-risk outpatient surgery and all used the anti-inflammatory bundle. All patients had a significant decrease in postoperative pain scores (p = 0.001). There was no significant difference in postoperative pain scores between those who followed the anti-inflammatory bundle alone and those who also used opioids (mean 2.2 vs 3.1/10). Twenty-five (21%) patients were using opioids preoperatively and 50 (42%) postoperatively. Of those using opioids preoperatively, six (24%) patients used the anti-inflammatory bundle alone and avoided opioids postoperatively. CONCLUSIONS: For 58% of our patients, an anti-inflammatory bundle alone provided adequate pain control after a low-risk outpatient operation, such as hernia repair. Our practice uses the anti-inflammatory bundle for all patients. Our goal is to reduce both the need for opioids and the surgeon's contribution to the opioid epidemic.

Patients With Systemic Reaction to Their Hernia Mesh: An Introduction to Mesh Implant Illness.

In our practice, we have noticed an increased number of patients requiring mesh removal due to a systemic reaction to their implant. We present our experience in diagnosing and treating a subpopulation of patients who require mesh removal due to a possible mesh implant illness (MII). All patients who underwent mesh removal for indication of mesh reaction were captured from a hernia database. Data extraction focused on the patients' predisposing medical conditions, presenting symptoms suggestive of mesh implant illness, types of implants to which reaction occurred, and postoperative outcome after mesh removal. Over almost 7 years, 165 patients had mesh removed. Indication for mesh removal was probable MII in 28 (17%). Most were in females (60%), average age was 46 years, with average pre-operative pain score 5.4/10. All patients underwent complete mesh removal. Sixteen (57%) required tissue repair of their hernia; 4 (14%) had hybrid mesh implanted. Nineteen (68%) had improvement and/or resolution of their MII symptoms within the first month after removal. We present insight into a unique but rising incidence of patients who suffer from systemic reaction following mesh implantation. Predisposing factors include female sex, history of autoimmune disorder, and multiple medical and environmental allergies and sensitivities. Presenting symptoms included spontaneous rashes, erythema and edema over the area of implant, arthralgia, headaches, and chronic fatigue. Long-term follow up after mesh removal confirmed resolution of symptoms after mesh removal. We hope this provides greater attention to patients who present with vague, non-specific but debilitating symptoms after mesh implantation.

New Traditional Chinese Medicine Supplement Reduces Pain Faster than Conventional Pain Pills Alone: A Phase I/II Prospective, Double-Blinded Placebo-Controlled Randomized Trial.

BACKGROUND: The opioid crisis demands novel solutions for postoperative pain control. Traditional Chinese medicine (TCM) has used herbs for the treatment of pain for thousands of years. We studied whether a synergistic multimodal TCM supplement could reduce the need for conventional pain pills for low risk surgical procedures. METHODS: In a Phase I/II, prospective, double-blind, placebo-controlled, randomized clinical trial (PRCT), 93 patients were randomized to either TCM supplement or placebo oral medication for low-risk outpatient surgical procedures. Study medications began 3 days preoperatively and continued for 5 days postoperatively. Conventional pain pill use was not restricted. Patients were monitored postoperatively for all forms of pain pill use (Pain Pill Scoring Sheet) and subjective pain ratings (Brief Pain Inventory Short Form). Primary outcomes included type and number of pain pills used and subjective pain ratings. Secondary outcomes included an assessment of mood, general activity, sleep, and enjoyment of life. RESULTS: TCM use well tolerated. Conventional pain pill use was similar between groups. Linear regression analysis revealed that TCM reduced postoperative pain 3 times faster than placebo (P < .0001) with a 4-fold greater magnitude of relief by postoperative day 5 (P = .008). TCM also significantly improved sleep habits (P = .049) during the postoperative period. TCM effect was independent of type of surgery or amount of preoperative pain. DISCUSSION: This PRCT is the first to show that a multimodal, synergistic TCM supplement is safe and can effectively reduce acute postoperative pain more rapidly, and to a lower level, than conventional pain pills alone.

Expert Consensus for Key Features of Operative Reports of Ventral Hernia.

BACKGROUND: Operative reports are important documents; however, standards for critical elements of operative reports are general and often vague. Hernia surgery is one of the most common procedures performed by general surgeons, so the aim of this project was to develop a Delphi consensus on critical elements of a ventral hernia repair operative report. STUDY DESIGN: The Delphi method was used to establish consensus on key features of operative reports for ventral hernia repair. An expert panel was selected and questionnaires were distributed. The first round of voting was open-ended to allow participants to recommend what details should be included. For the second round the questionnaire was distributed with the items that did not have unanimous responses along with free text comments from the first round. RESULTS: Eighteen surgeons were approached, of which 11 completed both rounds. Twenty items were on the initial questionnaire, of which 11 had 100% agreement. Of the remaining 9 items, after the second questionnaire an additional 7 reached consensus. CONCLUSION: Ventral hernia repairs are a common and challenging problem and often require reoperations. Surgeons frequently refer to previous operative notes to guide future procedures, which requires detailed and comprehensive operative reports. This Delphi consensus was able to identify key components needed for an operative report describing ventral hernia repair.

Surgical Society Podcasts: A Novel Way to Engage and Educate the Community.

BACKGROUND: Podcasts are increasingly being utilized in the surgical field as an asynchronous educational resource. This article discusses podcasts devoted to the field of surgery and their growing contribution to surgical education. METHODS: We provide examples of current podcasts and their varied structures, including those that distribute clinical and educational content, discuss recent literature and advancements, interview leaders in the field, and/or showcase unique perspectives on topics such as career development, diversity, and wellness. RESULTS AND CONCLUSIONS: Podcasts generated from surgical societies stand on unique ground to educate and engage the surgical community.

Leveraging Twitter and its Unique #HashTag Capability: A Novel Social Media Resource From the European Hernia Society.

Background: Digital and Social Media (#SoMe) platforms have revolutionized the way information is shared, classified and accessed among medical professionals worldwide. The aim of this study was to review the hashtags used on Twitter by @EuroHerniaS to provide a practical roadmap for easier social media utilization for hernia surgery stakeholders. Methods: The hashtags used in tweets and retweets of the @EuroHerniaS Twitter feed were collated since its foundation in November 2016. Results: The first hashtag used was #HerniaSurgery. Since foundation to July 2021, the @EuroHerniaS Twitter feed has used 90 separate hashtags. The number of new hashtags per year was increasing leading to the development of an online library. The increasing diversity of hernia related hashtags allows for the more detailed posting and searching of hernia related information on the #SoMe platform Twitter. Conclusion: The more detailed use of hashtags on Twitter is to be encouraged. Hernia surgeons can make use of them both when posting and reviewing posts to aid the categorization of posts.

#Mesh: Social Media and Its Influence on Perceptions in Hernia Repair.

Social media can influence public perception in health care. By 2016, social media discussion against the use of transvaginal mesh influenced changes in Food and Drug Administration (FDA) regulations. We propose that the fate of hernia mesh will follow that of transvaginal mesh. Thus, we compare the trend of social media discussion of hernia and transvaginal mesh. Posts on Twitter and public Facebook groups were tracked for keywords "hernia," "hernia mesh," and "pelvic/vaginal mesh." Posts were categorized based on sentiment. On Facebook, 16 public groups with 14 526 members expressed negative sentiments in 95% of their 750 daily posts. Meanwhile, of the 1.1 million tweets on Twitter, those about hernia mesh were more negative (36.5%) than those about pelvic/vaginal mesh (29.2%). Three of the 5 top tweeters about hernia mesh and pelvic/vaginal mesh were linked to law firms involved in mesh-based lawsuits. The negative sentiments and steering of social media discussion by lawyers may directly affect surgical care. As surgeons, we may adapt our informed consent to acknowledge our patients' apprehensions about mesh. We may also be more involved in social media discussions ourselves. Meanwhile, we await FDA decisions in the regulation and availability of hernia mesh.

A new and standardized approach for trocar placement in laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Super-morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) present unique technical challenges. In our experience the ease of the operation and the operative time seem to be more dependent on body habitus than body mass index (BMI). We hypothesized that the distance between the xyphoid process and the umbilicus (the XU distance) correlated with surgical difficulty and described an original modification of trocar placement based on this measurement to improve the ease of the operation. METHODS: Seven hundred and seventy-four patients underwent LRYGB, and the XU distance was measured in a subset of 38 patients midway through the experience. The need for additional trocars was assessed intraoperatively and the relationship between the XU distance and the need for extra trocars was subsequently analyzed. A standardized approach for trocar placement was implemented in the second half of our series. The operative time was compared between the standardized and nonstandardized groups. RESULTS: Fifty percent of the patients required a five-trocar technique. Median XU distance in this group was 21.4 cm (range 17-25 cm). In the remaining 19 patients additional trocars were added; median XU distance was 27.3 cm (range 24-33 cm). From the 774 patients included in the study period, the operative time for the first 322 patients who were completed with a nonstandardized trocar approach was significantly longer than the subsequent 452 cases in which the standardized trocar approach was used (210 versus 173 min, p < 0.001). CONCLUSIONS: We define XU distance as the key element in determining the choice of trocar placement. When XU distance is less then 25 cm, the basic approach should be used and if it is greater than 25 cm, the advanced trocar approach is recommended. This standardized technique leads to decreased operative time and improved ease of operation.