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.

Does bowel preparation for inflammatory bowel disease surgery matter?

AIM: The purpose of this study was to determine if bowel preparation influences outcomes in patients with inflammatory bowel disease undergoing surgery. METHODS: The database of the American College of Surgeons National Surgical Quality Improvement Program, Procedure Targeted Colectomy, from 2012 to 2014 was analyzed. Inflammatory bowel disease patients undergoing colorectal resection with or without bowel preparation were included in the study. RESULTS: In all, 3679 patients with inflammatory bowel disease were identified. 42.5% had no bowel preparation, 21.5% had mechanical bowel preparation only, 8.8% had oral antibiotic bowel preparation only and 27.2% had combined mechanical and oral antibiotic preparation. Combined mechanical and oral antibiotic preparation is associated with lower rates of anastomotic leak, ileus, surgical site infection, organ space infection, wound dehiscence and sepsis/septic shock. CONCLUSION: Combined mechanical and oral antibiotic preparation for inflammatory bowel disease patients undergoing colectomy is associated with decreased rates of surgical site infection, anastomotic leak, ileus. Combined bowel preparation should be the standard of care for inflammatory bowel disease patients undergoing colorectal resection.

Safety of elective laparoscopic cholecystectomy in patients on dialysis: an analysis of the ACS NSQIP database.

BACKGROUND: Laparoscopic cholecystectomy (LC) remains one of the most frequently performed surgical procedures. The safety of LC in patients with renal disease is unclear. The postoperative outcomes of elective LC in patients on dialysis were studied and risk factors associated with longer length of stay and mortality were sought. METHODS: Patients who underwent LC between the dates of 1 January 2007 and 31 December 2010 at all hospitals in North America participating in the American College of Surgeons National Surgical Quality Improvement Project were reviewed. Data from 80,995 patients were collected, and the patients on dialysis (N = 512) were separated and compared with those of patients not on dialysis (N = 80,483). RESULTS: Postoperative complications for patients on and not on dialysis, respectively, included mortality (4.1 vs. 0.2%, p < 0.001), myocardial infarction (0.8 vs. 0.1%, p = 0.002), pneumonia (2.3 vs. 0.4%, p < 0.001), sepsis (3.1 vs. 0.4%, p < 0.001), and return to operating room (4.3 vs. 1.0%, p < 0.001). In patients on dialysis, multivariate analysis was used to identify risk factors, including congestive heart failure and prior cardiac surgery as significant independent predictors of longer length of stay and mortality. CONCLUSION: Patients on dialysis who undergo LC should be carefully selected due to the significantly higher complication and mortality rate. Several predictors of longer length of stay and mortality were identified that can determine which patients on dialysis are good candidates for LC.

Assessing the mFI-5 frailty score and functional status in geriatric patients undergoing inguinal hernia repairs.

PURPOSE: The modified 5-factor frailty index (mFI-5) is a prognostic tool based on five comorbidities from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database-hypertension, congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and non-independent functional status. Our study investigates the mFI-5 index's ability to predict morbidity, length of stay (LOS), and discharge destination in geriatric patients undergoing inguinal hernia repairs, as well as assesses the interplay of baseline functional status. METHODS: Patients aged ≥ 65 years who underwent inguinal or femoral hernia repairs from the 2018-2020 NSQIP database were studied. Separate analyses were performed for emergent and elective cohorts. Stratification was performed according to the sum of mFI-5 variables: mFI = 0, mFI = 1, mFI ≥ 2. RESULTS: A total of 41,897 consisted of 92.9% elective and 7.1% emergent cases. The sample was 37.8% mFI = 0, 47.2% mFI = 1, and 15.0% mFI ≥ 2. Median age was 73 (IQR 68-78). Of emergent mFI ≥ 2 cases, 24.2% had non-independent functional status, versus only 4.8% in elective cases. Area under the curve was calculated for emergent and elective groups, including mortality (0.86, 0.80), pneumonia (0.82, 0.77), discharge destination not home (0.78, 0.73), prolonged LOS (0.69, 0.66), and infection (0.71, 0.62). Of index variables, dependent functional status was correlated with increased complications in elective and emergent cohorts, while COPD was significant in elective cases (OR > 2.0, p < 0.05). CONCLUSION: The mFI-5 is predictive of complications in geriatric inguinal hernia repairs, especially in emergent cases. Frail patients with non-independent functional status are most at risk and, thus require proactive and watchful perioperative care.

Minimally invasive surgery for splenic malignancies.

While minimally invasive surgery, i.e. laparoscopy, has become well-accepted in the treatment algorithm for malignancies of the gastrointestinal tract and gynecologic tumors, the role of laparoscopy for malignancies involving the spleen is less clear. Initially described in 1992 for benign hematologic disease, laparoscopic splenectomy (LS) for splenic malignancy was avoided secondary to the severe hematologic disease, profound cytopenia, and massive splenomegaly frequently seen in these patients. As experience with LS grew and larger data were generated, it became clear that hematologic malignancy and splenomegaly could be safely managed laparoscopically. In experienced hands, LS can be used for the diagnosis and treatment of both lymphoproliferative and myeloproliferative disorders affecting spleen, in addition to splenic tumors of both primary and metastatic origin. LS can be performed from a lateral or anterior approach, and hand-assisted laparoscopic splenectomy can provide significant benefit in cases of massive splenomegaly. Preoperative imaging for accurate splenic measurement is invaluable to guide surgical planning. Triple vaccination should be given to all patients prior to surgery, and splenic artery embolization before surgery should be considered in patients with massive splenomegaly to reduce intraoperative bleeding. LS can be performed safely for nearly all cases of malignancy involving the spleen, and potentially offers significant advantages of decreased pain and recovery time while maintaining equivalent complications and survival compared to open splenectomy.

Hemoperitoneum following inguinal hernia repair: a case report.

Traditional inguinal herniorrhaphy continues to be one of the most common surgeries performed in the USA today. The procedure has developed into a straightforward, ambulatory procedure with postoperative complications being very rare. We describe the first report in the literature of the serious complication of hemoperitoneum after open inguinal hernia repair attributed to injury of the artery of Sampson.

Diaphragmatic eventration presenting as a recurrent diaphragmatic hernia.

Diaphragmatic eventration is an uncommon condition, usually discovered incidentally in asymptomatic patients. Even in symptomatic patients, the diagnosis can be challenging and should be considered among the differential diagnoses of diaphragmatic hernia. The correct diagnosis can often only be made in surgery. We describe the case of a 31-year-old patient with diaphragmatic eventration that was misdiagnosed as a recurrent congenital diaphragmatic hernia and review the corresponding literature.

Laparoscopic management of gastrointestinal stromal tumors.

BACKGROUND: Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs). Laparoscopic surgery should be considered for these tumors as their biologic behavior lends them to curative resection without requiring large margins or extensive lymphadenectomies. METHODS: A retrospective review was performed of patients who underwent laparoscopic treatment of GISTs by surgeons at the Mount Sinai Medical Center from 2000-2005. Records were reviewed with respect to patient demographics, medical history, diagnostic workup, operative details, postoperative course, and pathologic characteristics. RESULTS: Laparoscopic surgery was attempted in 43 patients with GISTs. The average age was 65 years and 21 were women. Fifty-six percent of patients presented with anemia or gastrointestinal bleeding. The tumors were located in the stomach (65%) and in the small bowel (35%). The mean tumor sizes were 4.6 cm (stomach) and 3.7 cm (small bowel). Gastric operations included laparoscopic wedge (29%), sleeve (21%), and partial (29%) gastrectomies. The three gastric conversions were due to local invasion of tumor into adjacent organs or proximity to the gastroesophageal junction. Small bowel operations included laparoscopic resections with extracorporeal (47%) and intracorporeal anastamoses (33%). Conversion in small bowel operations was associated with coincidental pathology in addition to the GIST. This consisted of an associated bowel perforation and a synchronous colonic carcinoma. There was one mortality and a 9% morbidity rate, including an evisceration requiring reoperation. All tumors were pathologically confirmed with CD117 immunohistochemistry. CONCLUSIONS: In light of their biologic behavior, GISTs should be considered for laparoscopic resection. This minimally invasive approach to these tumors can be performed safely and reliably.

The role of mental rotation and memory scanning on the performance of laparoscopic skills: a study on the effect of camera rotational angle.

OBJECTIVE: The rotational angle of the laparoscopic image relative to the true horizon has an unknown influence on performance in laparoscopic procedures. This study evaluates the effect of increasing rotational angle on surgical performance. METHODS: Surgical residents (group 1) (n = 6) and attending surgeons (group 2) (n = 4) were tested on two laparoscopic skills. The tasks consisted of passing a suture through an aperture, and laparoscopic knot tying. These tasks were assessed at 15 degrees intervals between 0 degrees and 90 degrees , on three consecutive repetitions. The participant's performance was evaluated based on the time required to complete the tasks and number of errors incurred. RESULTS: There was an increasing deterioration in suturing performance as the degree of image rotation was increased. Participants showed a statistically significant 20-120% progressive increase in time to completion of the tasks (p = 0.004), with error rates increasing from 10% to 30% (p = 0.04) as the angle increased from 0 degrees to 90 degrees. Knot-tying performance similarly showed a decrease in performance that was evident in the less experienced surgeons (p = 0.02) but with no obvious effect on the advanced laparoscopic surgeons. CONCLUSIONS: When evaluated independently and as a group, both novice and experienced laparoscopic surgeons showed significant prolongation to completion of suturing tasks with increased errors as the rotational angle increased. The knot-tying task shows that experienced surgeons may be able to overcome rotational effects to some extent. This is consistent with results from cognitive neuroscience research evaluating the processing of directional information in spatial motor tasks. It appears that these tasks utilize the time-consuming processes of mental rotation and memory scanning. Optimal performance during laparoscopic procedures requires that the rotation of the camera, and thus the image, be kept to a minimum to maintain a stable horizon. New technology that corrects the rotational angle may benefit the surgeon, decrease operating time, and help to prevent adverse outcomes.

Patient profiles and outcomes following repair of irreducible and reducible Ventral Wall Hernias.

PURPOSE: The belief that irreducible hernias are repaired less successfully and with higher morbidity drives patients to seek elective repair. The aims of this study were threefold. First, this study sought to compare characteristics of patients undergoing irreducible and reducible ventral hernia repair. Second, to compare morbidity rates. Third, to determine which factors, including irreducibility, might be associated with recurrence. METHODS: This observational study was a retrospective review of 252 consecutive ventral hernia patients divided into two cohorts: 101 patients who underwent repair of an irreducible ventral hernia, and 152 patients underwent repair of a reducible ventral hernia. The mean follow-up time was approximately 4 years in both groups. RESULTS: Patients undergoing repair of irreducible hernias had higher median BMI (31 vs. 27 kg/m2, p = 0.005), had their hernias longer (median 34 months compared to 12 months, p = 0.043), had more defects on average (mean 1.8 vs. 1.4, p < 0.001), and were more likely to be symptomatic (83 vs. 55%, p = 0.002). Interestingly, neither hernia size (p = 0.821), nor the location of hernia (p = 0.261) differed significantly between the two groups. Morbidity rates, including rates of surgical site infection, obstruction, and recurrence, did not differ significantly; nor did recurrence-free survival (RFS) distributions. Risk factors for hernia recurrence on multivariate analysis included the repaired hernia being itself recurrent (HR = 2.06, 95% CI = 1.07-3.99, p = 0.031), the occurrence of post-operative surgical site infection (HR = 5.10, 95% CI = 2.18-11.91, p < 0.001), and the occurrence of post-operative intestinal obstruction (HR = 5.18, 95% CI = 1.82-14.75, p = 0.002). Irreducibility was not a significant predictor of recurrence (p = 0.152). CONCLUSION: Despite differing profiles, patients with these two types of hernias did not have statistically significant differences in morbidity. Recurrence was not observed to be associated with irreducibility but was found to be associated with other post-operative complications.