Prophylactic Mesh-related Reoperations and Mesh-related Problems During Subsequent Relaparotomies: Long-term Results From the PRIMA Trial.

OBJECTIVE: This study aimed to evaluate all mesh-related problems during reoperations after mesh-reinforcement 15 years after the start of the PRIMA trial. SUMMARY BACKGROUND DATA Prophylactic mesh reinforcement during closure of a midline laparotomy has proven to reduce the incidence of incisional hernia, especially in high-risk patients, but long-term mesh-related morbidity is largely unknown. METHODS: Patients receiving a prophylactic onlay or retro-rectus mesh in the PRIMA trial between 2009 and 2012 were included on an as-treated basis from participating centers that made reoperation notes available. Main outcomes were the incidences of complications requiring mesh explantation, mesh-related ileus, and mesh-related problems during laparotomy for other diagnoses. METHODS: Out of 373 patients randomized to prophylactic mesh reinforcement, 242 were included: 127 with onlay and 115 patients with retrorectus mesh. Median follow-up is 27 months (IQR 12-78). Thirty-four patients underwent reoperation for any reason during entire follow-up, 22 after onlay (17.3%) and 12 after retrorectus mesh (10.4%). Reoperation rate for complications that required mesh explantation was 4/127 (3.1%) after onlay and 0/115 (0%) after retrorectus mesh. Mesh-related ileus occurred in none of the onlay group, and 3/115 (2.6%) in the retrorectus group. During subsequent laparotomies for other primary diagnoses, adhesions to the mesh were noted in 3/10 patients in the onlay group and 1/5 patients in the retro-rectus group. Overall, the mesh was removed in 10/127 (7.9%) in the onlay group and 7/115 (6.1%) patients in the retro-rectus group. CONCLUSIONS: In high-risk patients receiving a prophylactic mesh during midline laparotomy closure, low incidences of mesh-related complications requiring reoperation and mesh-related problems during unrelated subsequent laparotomies were found, for both the onlay and retrorectus techniques.

Intraoperative Music to Promote Patient Outcome (IMPROMPTU): A Double-Blind Randomized Controlled Trial.

INTRODUCTION: Perioperative music can have beneficial effects on postoperative pain, anxiety, opioid requirement, and the physiological stress response to surgery. The aim was to assess the effects of intraoperative music during general anesthesia in patients undergoing surgery for esophagogastric cancer. MATERIALS AND METHODS: The IMPROMPTU study was a double-blind, placebo-controlled, randomized multicenter trial. Adult patients undergoing surgery for stage II-III esophagogastric cancer were eligible. Exclusion criteria were a hearing impairment, insufficient Dutch language knowledge, corticosteroids use, or objection to hearing unknown music. Patients wore active noise-cancelling headphones intraoperatively with preselected instrumental classical music (intervention) or no music (control). Computerized randomization with centralized allocation, stratified according to surgical procedure using variable block sizes, was employed. Primary endpoint was postoperative pain on the first postoperative day. Secondary endpoints were postoperative pain during the first postoperative week, postoperative opioid requirement, intraoperative medication requirement, the stress response to surgery, postoperative complication rate, length of stay, and mortality, with follow-up lasting 30 d. RESULTS: From November 2018 to September 2020, 145 patients were assessed and 83 randomized. Seventy patients (music n = 31, control n = 39) were analyzed. Median age was 70 [IQR 63-70], and 48 patients (69%) were male. Music did not reduce postoperative pain (numeric rating scale 1.8 (SD0.94) versus 2.0 (1.0), mean difference -0.28 [95% CI -0.76-0.19], P = 0.236). No statistically significant differences were seen in medication requirement, stress response, complication rate, or length of stay. CONCLUSIONS: Intraoperative, preselected, classical music during esophagogastric cancer surgery did not significantly improve postoperative outcome and recovery when compared to no music using noise-cancelling headphones.

Implementation of music in the perioperative standard care of colorectal surgery (IMPROVE study).

AIM: Patients undergoing surgery experience perioperative anxiety and pain. Music has been shown to reduce perioperative anxiety, pain and medication requirement. This study assessed the feasibility and effectiveness of implementing a perioperative music intervention. METHOD: A prospective pre- and post-implementation pilot study was conducted to assess adherence to the intervention and the initial effect of music on postoperative pain scores (Numerical Rating Scale, 0-10) compared to a control group. Secondary outcomes encompassed pain scores throughout hospital admission, anxiety levels, medication usage, complications and hospital stay length. RESULTS: Adherence to the music intervention was preoperative 95.2%, intraoperative 95.7%, postoperative 31.9% and overall 29.7%. The intervention did influence postoperative pain. Patient's willingness to receive music was high (73%), they appreciated the intervention (median 8.0, interquartile range 7.0-9.0) and healthcare professionals were willing to apply the intervention. Music significantly reduced postoperative anxiety (2.0 vs. 3.0, p = 0.02) and the consumption of benzodiazepines on the first postoperative day (number of patients: zero [0%] vs. five [10%], p = 0.04). CONCLUSION: Implementation of music resulted in reduced postoperative anxiety and decreased consumption of benzodiazepines, and the strategy was feasible, but adjustments are needed to improve postoperative adherence. Both patients and healthcare professionals had a positive attitude towards the intervention.

Implementation of perioperative music in day care surgery.

BACKGROUND: Perioperative music can have beneficial effects on postoperative pain and perioperative opioid requirement. This study aims to assess the implementation feasibility of music in day care surgery through adherence to implementation, as well as its effects. METHODS: This implementation study employed a prospective single-center study design. Perioperative music was implemented as part of standard surgical care during day care surgery procedures. The music intervention consisted of preselected playlists. Primary outcome was adherence to implementation. Barriers and attitudes towards music of patients and perioperative care providers were evaluated. Furthermore, the effects of music were assessed through a matched cohort analysis. This study was registered with the Netherlands Trial Register (NL8213). RESULTS: From January to April 2020, a total of 109 patients received the music intervention and 97 were analyzed after matching to retrospective controls. Adherence rate to the music intervention was 92% preoperatively, 81% intraoperatively, and 86% postoperatively, with 83% of patients satisfied with the preselected music, and 93% finding music to be beneficial to surgical care. All health care providers believed perioperative music to be beneficial (63%) or were neutral (37%) towards its use. Postoperative pain was not significantly different (mean numeric rating scale 0.74; the music intervention group versus 0.68; control group, p = .363). Although not statistically significant, postoperative opioid requirement in the music group was lower (30% versus 40%, p = .132). CONCLUSION: Perioperative music implementation in day care surgery is feasible with high adherence rates, patient satisfaction levels, and positive attitudes of health care providers towards its use.

The feasibility and added value of mapping music during awake craniotomy: A systematic review.

The value of mapping musical function during awake craniotomy is unclear. Hence, this systematic review was conducted to examine the feasibility and added value of music mapping in patients undergoing awake craniotomy. An extensive search, on 26 March 2021, in four electronic databases (Medline, Embase, Web of Science and Cochrane CENTRAL register of trials), using synonyms of the words "Awake Craniotomy" and "Music Performance," was conducted. Patients performing music while undergoing awake craniotomy were independently included by two reviewers. This search resulted in 10 studies and 14 patients. Intra-operative mapping of musical function was successful in 13 out of 14 patients. Isolated music disruption, defined as disruption during music tasks with intact language/speech and/or motor functions, was identified in two patients in the right superior temporal gyrus, one patient in the right and one patient in the left middle frontal gyrus and one patient in the left medial temporal gyrus. Pre-operative functional MRI confirmed these localizations in three patients. Assessment of post-operative musical function, only conducted in seven patients by means of standardized (57%) and non-standardized (43%) tools, report no loss of musical function. With these results, we conclude that mapping music is feasible during awake craniotomy. Moreover, we identified certain brain regions relevant for music production and detected no decline during follow-up, suggesting an added value of mapping musicality during awake craniotomy. A systematic approach to map musicality should be implemented, to improve current knowledge on the added value of mapping musicality during awake craniotomy.

Favorable Outcomes After Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Noncomplex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-analysis.

OBJECTIVE: To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair. SUMMARY BACKGROUND DATA: Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For noncomplex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking. METHODS: Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models. RESULTS: Ninety-three studies representing 12,440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% [95% confidence interval (CI): 2.2%-4.2%, n = 11,049] after minimally 12months and 4.1%, (95%CI: 2.9%-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2%-6.4%, n = 4891) and 5.5% (95%CI: 4.4%-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair [odds ratios (OR): 0.27, 95%CI: 0.15-0.51, P < 0.001] and equal recurrence rates compared to intraperitoneal onlay mesh (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, P = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03 -3.14, P = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7%-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8%-2.8%, n = 982), albeit based on non-randomized studies. CONCLUSIONS: Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except SSI. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

Implementation of music in colorectal perioperative standard care-barriers and facilitators among patients and healthcare professionals.

AIM: Perioperative anxiety and pain are still prevalent among patients undergoing surgery. Inflammatory bowel disease and colorectal cancer patients are known to have higher anxiety rates than the general population. Perioperatively applied music intervention has been proven to be effective in reducing perioperative anxiety and pain, resulting in a decrease of intra-operative sedative use, postoperative opioid requirement and neurohormonal stress response. IMPROVE evaluates the adherence to music intervention in colorectal perioperative standard care during systematic implementation. METHOD: The Consolidated Framework for Implementation Research (CFIR) was used for implementation in three steps. This study addresses the first step in which barriers and facilitators for implementing perioperative music were identified by surveying patients who underwent colorectal surgery and healthcare professionals involved in perioperative care. Also, perioperative anxiety scores were assessed and data on perioperative pain was collected from the patients' medical records. RESULTS: Fifty patients and 69 professionals (response rate 68.3%) were surveyed. For patients, all domains of the CFIR were facilitating implementation. The median reported preoperative and postoperative anxiety scores were 4.5 (1.0-7.0) and 3.0 (1.0-5.75) respectively. The median postoperative pain score on the first postoperative day was 2.8 (2.0-3.7). Also, for professionals most domains were facilitating, except for some factors related to work climate and culture among nurses. CONCLUSIONS: In this study it was identified that facilitating factors for implementing music in standard perioperative care were more prominent in both patients and healthcare professionals and therefore successful implementation is probable. Also, this study provides a guideline for assessing facilitators and barriers in other settings.

The Perception and Attitude Toward Noise and Music in the Operating Room: A Systematic Review.

BACKGROUND: Environmental noise pollution is regarded as a general stressor. Noise levels frequently exceed recommended noise levels by the World Health Organization in hospitals, especially in the operation room. The aim of this systematic review was to assess the effects of noise pollution on patient outcome and performance by operation room staff. In addition, the perception and attitude toward playing music in the operation room, which can increase noise levels, were assessed as well. MATERIALS AND METHODS: A systematic literature search of the databases Embase, Medline Ovid, and Cochrane from date of database inception until October 16th, 2020 using the exhaustive literature search method was performed. Prospective studies evaluating the effect of noise on the patient, surgeons, anesthesiologists, nurses, and other operation room staff, or perception and attitude toward playing music in the operation room, were included. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and was registered with PROSPERO (ID: 208282). RESULTS: The literature search generated 4758 articles, and 22 prospective studies (3507 participants) were included. Three of the four studies that investigated the effect of noise on patient outcome reported a significant reduction of complication rate in surgical patients, when noise levels were lower. Six studies assessed the effect of noise in the operation room on the staff (1383 participants). Over half of the surveyed staff found noise levels to be a disturbing stressor and negatively impact performance. Although music increased decibel levels in the operation room, most surveyed staff was positively predisposed toward playing music during surgery, believing it to improve both individual and team performance. In general, music was not considered to be distracting or impairing communication. CONCLUSIONS: Higher noise levels seem to have a negative effect on patient outcome and adversely affect performance by members in the operation room. Further research is needed to assess whether this knowledge can benefit patient outcome and surgical performance. Notably, attitude of surgical team members toward music during surgery is generally regarded favorable.

The effect of preferred music on mental workload and laparoscopic surgical performance in a simulated setting (OPTIMISE): a randomized controlled crossover study.

BACKGROUND: Worldwide, music is commonly played in the operation room. The effect of music on surgical performance reportedly has varying results, while its effect on mental workload and key surgical stressor domains has only sparingly been investigated. Therefore, the aim is to assess the effect of recorded preferred music versus operating room noise on laparoscopic task performance and mental workload in a simulated setting. METHODS: A four-sequence, four-period, two-treatment, randomized controlled crossover study design was used. Medical students, novices to laparoscopy, were eligible for inclusion. Participants were randomly allocated to one of four sequences, which decided the exposure order to music and operation room noise during the four periods. Laparoscopic task performance was assessed through motion analysis with a laparoscopic box simulator. Each period consisted of ten alternating peg transfer tasks. To account for the learning curve, a preparation phase was employed. Mental workload was assessed using the Surgery Task Load Index. This study was registered with the Netherlands Trial Register (NL7961). RESULTS: From October 29, 2019 until March 12, 2020, 107 participants completed the study, with 97 included for analyzation. Laparoscopic task performance increased significantly during the preparation phase. No significant beneficial effect of music versus operating room noise was observed on time to task completion, path length, speed, or motion smoothness. Music significantly decreased mental workload, reflected by a lower score of the total weighted Surgery Task Load Index in all but one of the six workload dimensions. CONCLUSION: Music significantly reduced mental workload overall and of several previously identified key surgical stressor domains, and its use in the operating room is reportedly viewed favorably. Music did not significantly improve laparoscopic task performance of novice laparoscopists in a simulated setting. Although varying results have been reported previously, it seems that surgical experience and task demand are more determinative.

Outcomes of Incisional Hernia Repair Surgery After Multiple Re-recurrences: A Propensity Score Matched Analysis.

BACKGROUND: Patients with a re-recurrent hernia may account for up to 20% of all incisional hernia (IH) patients. IH repair in this population may be complex due to an altered anatomical and biological situation as a result of previous procedures and outcomes of IH repair in this population have not been thoroughly assessed. This study aims to assess outcomes of IH repair by dedicated hernia surgeons in patients who have already had two or more re-recurrences. METHODS: A propensity score matched analysis was performed using a registry-based, prospective cohort. Patients who underwent IH repair after ≥ 2 re-recurrences operated between 2011 and 2018 and who fulfilled 1 year follow-up visit were included. Patients with similar follow-up who underwent primary IH repair were propensity score matched (1:3) and served as control group. Patient baseline characteristics, surgical and functional outcomes were analyzed and compared between both groups. RESULTS: Seventy-three patients operated on after ≥ 2 IH re-recurrences were matched to 219 patients undergoing primary IH repair. After propensity score matching, no significant differences in patient baseline characteristics were present between groups. The incidence of re-recurrence was similar between groups (≥ 2 re-recurrences: 25% versus control 24%, p = 0.811). The incidence of complications, as well as long-term pain, was similar between both groups. CONCLUSION: IH repair in patients who have experienced multiple re-recurrences results in outcomes comparable to patients operated for a primary IH with a similar risk profile. Further surgery in patients who have already experienced multiple hernia re-recurrences is justifiable when performed by a dedicated hernia surgeon.

Perception of auditory stimuli during general anesthesia and its effects on patient outcomes: a systematic review and meta-analysis.

PURPOSE: Interest in implicit memory formation and unconscious auditory stimulus perception during general anesthesia has resurfaced as perioperative music has been reported to produce beneficial effects. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating explicit and implicit memory formation during general anesthesia and its effects on postoperative patient outcomes and recovery. SOURCE: We performed a systematic literature search of Embase, Ovid Medline, and Cochrane Central from inception date until 15 October 2020. Eligible for inclusion were RCTs investigating intraoperative auditory stimulation in adult surgical patients under general anesthesia in which patients, healthcare staff, and outcome assessors were all blinded. We used random effects models for meta-analyses. This study adhered to the PRISMA guidelines and was registered in PROSPERO (CRD42020178087). PRINCIPAL FINDINGS: Fifty-three (4,200 patients) of 5,859 identified articles were included. There was evidence of implicit memory formation in seven out of 17 studies (41%) when assessed using perceptual priming tasks. Mixed results were observed on postoperative behavioural and motor response after intraoperative suggestions. Intraoperative music significantly reduced postoperative pain (standardized mean difference [SMD], -0.84; 95% confidence interval [CI], -1.1 to -0.57; P < 0.001; I2 = 0; n = 226) and opioid requirements (SMD, -0.29; 95% CI, -0.57 to -0.015; P = 0.039; I2 = 36; n = 336), while positive therapeutic suggestions did not. CONCLUSION: The results of this systematic review and meta-analysis show that intraoperative auditory stimuli can be perceived and processed during clinically adequate, general anesthesia irrespective of surgical procedure severity, leading to implicit memory formation without explicit awareness. Intraoperative music can exert significant beneficial effects on postoperative pain and opioid requirements. Whether the employed intraoperative anesthesia regimen is of influence is not yet clear.

RéSUMé: OBJECTIF: L'intérêt pour la création de mémoire implicite et la perception inconsciente de stimuli auditifs pendant l'anesthésie générale a refait surface depuis qu'il a été rapporté que l'audition de musique périopératoire produisait des effets bénéfiques. Nous avons mené une revue systématique et une méta-analyse des études randomisées contrôlées (ERC) évaluant la création de mémoire explicite et implicite pendant l'anesthésie générale et ses effets sur les devenirs postopératoires et le rétablissement des patients. SOURCES: Nous avons effectué une recherche documentaire systématique dans les bases de données Embase, Ovid Medline et Cochrane Central depuis leur date de création jusqu'au 15 octobre 2020. Étaient admissibles à l'inclusion les ERC évaluant la stimulation auditive peropératoire chez les patients chirurgicaux adultes sous anesthésie générale, dans lesquelles les patients, le personnel de soins de santé et les évaluateurs des devenirs étaient tous en aveugle. Nous avons utilisé des modèles à effets aléatoires pour les méta-analyses. Cette étude a respecté les lignes directrices PRISMA et a été enregistrée dans le registre PROSPERO (CRD42020178087). CONSTATATIONS PRINCIPALES: Cinquante-trois des 5859 articles identifiés (4200 patients) ont été inclus. Sept études sur 17 (41 %) comportaient des données probantes concernant la création de mémoire implicite lorsqu'elle était évaluée à l'aide de tâches d'amorçage perceptif. Des résultats mitigés ont été observés sur la réponse comportementale et motrice postopératoire après des suggestions peropératoires. La musique peropératoire a considérablement réduit la douleur postopératoire (différence moyenne standardisée [DMS], -0,84; intervalle de confiance [IC] de 95 %, -1,1 à -0,57; P < 0,001; I2 = 0; n = 226) et les besoins en opioïdes (DMS, -0,29; IC 95 %, -0,57 à -0,015; P = 0,039; I2 = 36; n = 336), mais pas les suggestions thérapeutiques positives. CONCLUSION: Les résultats de cette revue systématique et méta-analyse montrent que les stimuli auditifs peropératoires peuvent être perçus et traités pendant une anesthésie générale cliniquement adéquate, indépendamment de la gravité de l'intervention chirurgicale, menant à la création de mémoire implicite sans conscience explicite. La musique peropératoire peut avoir des effets bénéfiques significatifs sur la douleur postopératoire et les besoins en opioïdes. Il n'est pas encore possible de déterminer si le type d'anesthésie peropératoire utilisé a une influence.

Calcification of the Aorta-Iliac Trajectory as a Risk Factor for Anastomotic Leakage in Colorectal Surgery: Individual Patient Data Meta-Analysis and Systematic Review.

OBJECTIVE: The purpose of this review is to evaluate the relevance of vascular calcification as a potential risk factor for anastomotic leakage in colorectal surgery. METHOD: The Embase, Medline, PubMed, and Cochrane databases and Google Scholar were systematically searched. Studies that assessed calcification of the aorta-iliac trajectory in patients who underwent colorectal surgery were included. An independent patient data meta-analysis was performed as follows: based on the heterogeneity of the study population, a "random-effects model" or "fixed-effects model" was used to perform a multivariable logistic regression and calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I2-test. RESULTS: From a total of 457 articles retrieved, eight fell within the scope of the review, with a total of 2010 patients. Anastomotic leakage was found at a mean rate of 11.1% (SD 4.9%). In these eight studies, four different calcification scoring methods were used, which made a single structured meta-analysis not feasible. Therefore, an independent patient data meta-analysis on the most frequently used calcification scoring method was performed, including three studies with a total of 396 patients. After multivariable analyses, no significant association was found between anastomotic leakage and the amount of calcification in the aorta-iliac trajectory. The remaining three scoring methods were evaluated. In four of the five studies, vascular calcification was associated with anastomotic leakage after colorectal surgery. CONCLUSION: In contrast to previous studies, an individual patient data meta-analysis found no association between calcification and anastomotic leakage in colorectal surgery after multivariable analysis that considered a single calcification measurement method. In addition, this study demonstrated several scoring methods for arterial calcification and the need for a standardized technique. Therefore, the authors would recommend prospective studies using a calcification scoring method that includes grade of stenosis due to its potential to preoperatively improve perfusion by endovascular treatment.

The Effect of Perioperative Music on Medication Requirement and Hospital Length of Stay: A Meta-analysis.

OBJECTIVE: To assess and quantify the effect of perioperative music on medication requirement, length of stay and costs in adult surgical patients. SUMMARY BACKGROUND DATA: There is an increasing interest in nonpharmacological interventions to decrease opioid analgesics use, as they have significant adverse effects and opioid prescription rates have reached epidemic proportions. Previous studies have reported beneficial outcomes of perioperative music. METHODS: A systematic literature search of 8 databases was performed from inception date to January 7, 2019. Randomized controlled trials investigating the effect of perioperative music on medication requirement, length of stay or costs in adult surgical patients were eligible. Meta-analysis was performed using random effect models, pooled standardized mean differences (SMD) were calculated with 95% confidence intervals (CI). This study was registered with PROSPERO (CRD42018093140) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. RESULTS: The literature search yielded 2414 articles, 55 studies (N = 4968 patients) were included. Perioperative music significantly reduced postoperative opioid requirement (pooled SMD -0.31 [95% CI -0.45 to -0.16], P < 0.001, I = 44.3, N = 1398). Perioperative music also significantly reduced intraoperative propofol (pooled SMD -0.72 [95% CI -1.01 to -0.43], P < 0.00001, I = 61.1, N = 554) and midazolam requirement (pooled SMD -1.07 [95% CI -1.70 to -0.44], P < 0.001, I = 73.1, N = 184), while achieving the same sedation level. No significant reduction in length of stay (pooled SMD -0.18 [95% CI -0.43 to 0.067], P = 0.15, I = 56.0, N = 600) was observed. CONCLUSIONS: Perioperative music can reduce opioid and sedative medication requirement, potentially improving patient outcome and reducing medical costs as higher opioid dosage is associated with an increased risk of adverse events and chronic opioid abuse.

Zinc-Impregnated Mesh for Abdominal Wall Repair Reduces Infection in a Rat Model of Peritonitis.

BACKGROUND: The objective of this study was to assess whether a zinc-impregnated polypropylene mesh (ZnMesh) has better antibacterial properties in a contaminated environment compared with a regular polypropylene mesh. MATERIALS AND METHODS: Thirty-eight Wistar Han rats underwent cecal ligation and puncture to induce peritonitis 24 h before implantation of an intraperitoneal ZnMesh or a regular polypropylene mesh. Primary outcome was the number of colony forming units (CFU) per sample (mesh and abdominal wall). Secondary outcomes were macroscopic (incorporation of mesh, abscesses, and adhesions on mesh surface) and histological (inflammatory cell reaction, mesh-specific parameters, and collagen deposition) parameters. All outcomes were evaluated after 30 and 90 d. RESULTS: After 30 d, no significant difference in CFU per sample was present between the ZnMesh and control groups. After 90 d, a lower number of CFU per sample was present in the ZnMesh group compared with the control group (trypticase soy agar with 5% sheep blood: 0 log10 CFU/sample IQR: 0-1.40 versus 1.58 log10 CFU/sample IQR: 0-4.30, P = 0.012; MacConkey: 0 log10 CFU/sample IQR: 0-2.65 versus 1.18 log10 CFU/sample IQR: 0-4.04, P = 0.438). After 90 d, the percentage of adhesions on mesh surface was significantly higher in the ZnMesh group (95% IQR: 60%-100% versus 50% IQR: 23%-75%, P = 0.029). No differences were seen in other macroscopic outcomes or histology. CONCLUSIONS: A significantly lower number of CFU per sample was found in the ZnMesh group after 90 d. After 30 d, no statistically significant differences in CFU per sample were seen. This result suggests that the ZnMesh group has better antibacterial properties in a contaminated environment. However, this is at the cost of a significantly higher percentage of adhesions.

The Effects of Preferred Music on Laparoscopic Surgical Performance: A Randomized Crossover Study.

INTRODUCTION: Music can have a positive effect on stress and general task performance. This randomized crossover study assessed the effects of preferred music on laparoscopic surgical performance in a simulated setting. METHODS: Sixty medical students, inexperienced in laparoscopy, were included between June 2018 and November 2018. A randomized, 4-period, 4-sequence, 2-treatment crossover study design was used, with each participant acting as its own control. Participants performed four periods, consisting of five peg transfer tasks each period, on a laparoscopic box trainer: two periods while wearing active noise-cancelling headphones and two periods during music exposure. Participants were randomly allocated to a sequence determining the order of the four periods. The parameters time to task completion, path length and normalized jerk were assessed. Mental workload was assessed using the Surgical Task Load Index questionnaire. Also, heart rate and blood pressure were assessed. RESULTS: Participants performed the peg transfer task significantly faster [median difference: - 0.81 s (interquartile range, - 3.44-0.69) p = 0.037] and handled their instruments significantly more efficient as path length was reduced [median difference, - 52.24 mm (interquartile range, - 196.97-89.81) p = 0.019] when exposed to music. Also, mental workload was significantly reduced during music [median difference, - 2.41 (interquartile range, - 7.17-1.83) p = 0.021)]. No statistically significant effect was observed on heart rate and blood pressure. CONCLUSION: Listening to preferred music improves laparoscopic surgical performance and reduces mental workload in a simulated setting. TRIAL REGISTRATION: Trial registration number: NCT04111679.

Music Interventions in Pediatric Surgery (The Music Under Surgery In Children Study): A Randomized Clinical Trial.

BACKGROUND: Perioperative music interventions have been shown to reduce anxiety and pain in adults. This inexpensive, easily applicable intervention could be of benefit to children as well. Our objective was to determine the effects of music interventions on distress, anxiety, and postoperative pain in infants undergoing surgery. METHODS: The Music Under Surgery In Children study was designed as a parallel, single-blind, randomized controlled trial with an a priori formulated hypothesis. Data were collected between August 2015 and October 2016 in a single tertiary care children's hospital. There was a 24-hour follow-up with blind primary outcome assessment. A random sample of 432 eligible 0-3 years of age infants admitted for orchidopexy, hypospadias, or inguinal hernia repair receiving general anesthesia and caudal block were asked for participation. Subjects were assigned to a preoperative music intervention, pre- and intraoperative music intervention, or no music intervention (control) via random allocation using a computer-generated list with the use of opaque envelopes. The main outcome measure was the postoperative level of distress assessed with the COMFORT-Behavior scale, which is an observational scale; furthermore, preoperative level of distress, preoperative anxiety, and physiological measurements such as heart rate (HR) and blood pressure were measured. The trial was registered at the Dutch Trial Register, number NTR5402 (www.trialregister.nl). RESULTS: One hundred ninety-five infants with median age 6.9 months (interquartile range, 3.3-11.1) were randomized, 178 of whom were included in the primary analysis. A nonsignificant difference in COMFORT-Behavior scale scores between the pre- and intraoperative music intervention group and control group at 4 hours after surgery was found (mean difference, -1.22; 95% CI, 2.60-0.17; P = .085). Additional analysis showed weak nonsignificant evidence for an interaction effect between music exposure and COMFORT-Behavior score at baseline (P = .027 with a Bonferroni-adjusted significance level of .025). General linear modeling showed a statistically significantly reduced HR after the preoperative music intervention in the holding area in the combined preoperative music intervention and intraoperative music intervention group compared to the control group (P = .003). The differences in HR among the 3 study arms at all time points were not statistically significant (P = .069). CONCLUSIONS: Music interventions do not seem to benefit all young infants undergoing surgery. The potential benefits of music interventions in the preoperative period and in more distressed children warrant further exploration.

Non-cross-linked biological mesh in complex abdominal wall hernia: a cohort study.

PURPOSE: Complex abdominal wall hernia repair (CAWHR) is a challenging procedure. Mesh prosthesis is indicated, but the use of synthetic mesh in a contaminated area may add to overall morbidity. Biological meshes may provide a solution, but little is known about long-term results. The aim of our study was to evaluate clinical efficacy and patient satisfaction following Strattice™ (PADM) placement. METHODS: In this cohort study, all patients operated for CAWHR with PADM in three large community hospitals in Germany were included. Patients underwent abdominal examination, an ultrasound was performed, and patients completed quality-of-life questionnaires. The study was registered in ClinicalTrials.gov under Identifier NCT02168231. RESULTS: Twenty-seven patients were assessed (14 male, age 67.5 years, follow-up 42.4 months). The most frequent postoperative complication was wound infection (39.1%). In no case, the PADM had to be removed. Four patients had passed away. During outpatient clinic visit, six out of 23 patients (26.1%) had a recurrence of hernia, one patient had undergone reoperation. Five patients (21.7%) had bulging of the abdominal wall. Quality-of-life questionnaires revealed that patients judged their scar with a median 3.5 out of 10 points (0 = best) and judged their restrictions during daily activities with a median of 0 out of 10.0 (0 = no restriction). CONCLUSIONS: Despite a high rate of wound infection, no biological mesh had to be removed. In some cases, therefore, the biological meshes provided a safe way out of desperate clinical situations. Both the recurrence rate and the amount of bulging are high (failure rate 47.8%). The reported quality of life is good after repair of these complex hernias.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial.

BACKGROUND: Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias. METHODS: We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230. FINDINGS: Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths. INTERPRETATION: This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size. FUNDING: Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Resorbable Synthetic Meshes for Abdominal Wall Defects in Preclinical Setting: A Literature Review.

BACKGROUND: Prosthetic materials for the repair of abdominal wall defects have been studied extensively to improve outcome. A new approach can be the use of a slowly resorbable synthetic mesh, which aims to combine advantages of both synthetic and biological meshes. The objective of this review is to give an overview of the physicochemical characteristics and biomechanical, histological, and macroscopic outcome (recurrence, adhesion formation) of the use of resorbable synthetic meshes, for treatment and prevention of abdominal wall hernias, based on experimental studies. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only experimental studies were included. Outcome parameters were resorption, degradation, organization of connective tissue, inflammatory response, tensile strength, and amount of adhesion formation. Surgical characteristics were taken into account as well (type of defect, clean versus contaminated model, position mesh, repair of the defect, recurrences). RESULTS: In total, eleven articles were included. Three absorbable synthetic meshes are currently available: GORE BIO-A mesh (Gore), TIGR Matrix Surgical mesh (Novus Scientific), and Phasix mesh (Bard). Two studies concluded that, despite an early transient inflammatory reaction in the first months, remodeling was good in GORE BIO-A, 6-12 mo after augmentation or suture line reinforcement with only minimal to moderate adhesions when used intraperitoneally. The TIGR Matrix Surgical mesh shows only partial remodeling with a persistent foreign body reaction after 1 y. Phasix mesh seems to perform well in extraperitoneal implantation after 1 y in two studies, although the defect was small. Only two studies directly compared two resorbable synthetic meshes under the same circumstances. The latter also included a number of animals where the meshes were used in a contaminated nonhernia model. No hernia recurrences or deaths of animals were described in all studies. CONCLUSIONS: The use of resorbable synthetic meshes in the prevention or treatment of abdominal wall defects in animal experiments with small defects in clean setting seems safe, with no serious complications related to the device during short-term follow-up. However, there is no evidence available that can support the advantages of resorbable synthetic meshes over the use of synthetic or biological meshes, mostly due to lack of good data. More experimental studies are needed, followed by randomized controlled trials and prospective registries in humans with a sufficiently long follow-up period, to reveal the potential advantages in clinical practice.

The Effect of Perioperative Music on the Stress Response to Surgery: A Meta-analysis.

BACKGROUND: Current perioperative patient care aims to maintain homeostasis by attenuation of the stress response to surgery, as a more vigorous stress response can have detrimental effects on postoperative recovery. This systematic review and meta-analysis aims to assess the effect of perioperative music on the physiological stress response to surgery. METHODS: The Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar databases were searched from inception date until February 5, 2019, using a systematic literature search following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines for randomized controlled trials investigating the effect of music before, during, and/or after surgery in adult surgical patients on the stress response to surgery. Meta-analysis was performed using a random effects model and pooled standardized mean differences were calculated with 95% confidence intervals. This study was registered in the PROSPERO database (CRD42018097060). RESULTS: The literature search identified 1076 articles. Eighteen studies (1301 patients) were included in the systematic review, of which eight were included in the meta-analysis. Perioperative music attenuated the neuroendocrine cortisol stress response to surgery (pooled standardized mean difference -0.30, [95% confidence interval -0.53 to -0.07], P = 0.01, I2 = 0). CONCLUSIONS: Perioperative music can attenuate the neuroendocrine stress response to surgery.