Introduction
Anterior component separation (ACS) is a well-established, highly functional technique to achieve fascial closure in complex abdominal wall reconstruction (AWR). Unfortunately, ACS is ...also associated with an increased risk of wound complications. Perforator sparing ACS (PS-ACS) has more recently been introduced to maintain the subcutaneous perforators derived from the deep epigastric vessels. The aim of this study is to evaluate wound-related outcomes in patients undergoing open AWR after implementation of a PS-ACS technique.
Methods
A prospectively collected database were queried for patients who underwent open AWR and an ACS from 2006 to 2018. Patients who underwent PS-ACS were compared to patients undergoing ACS using standard statistical methods. Patients undergoing concomitant panniculectomy were included in the standard ACS group.
Results
In total, 252 patients underwent ACS, with 24 (9.5%) undergoing PS-ACS. Age and specific comorbidities were similar between groups (all
p
> 0.05) except for the PS-ACS groups having a higher rate of prior tobacco use (45.8% vs 19.6%,
p
= 0.003). Mean hernia defect area was 381.6 ± 267.0 cm
2
with 64.3% recurrent hernias, and both were similar between groups (all
p
> 0.05). The PS-ACS group did have more complex wounds with more Ventral Hernia Working Group Grade 3 and 4 hernias (
p
= 0.04). OR time and length of stay were similar between groups (all
p
> 0.05). Despite increased complexity, wound complication rates were much lower in the PS-ACS group (20.8% vs 46.1%,
p
= 0.02), and all specific wound complications were lower but not statistically different. Hernia recurrence rate was similar between PS-ACS and ACS groups (4.2% vs 7.0%,
p
> 0.99) with mean follow-up of 27.7 ± 26.9 months.
Conclusions
In complex AWR, preservation of the deep epigastric perforating vessels during ACS significantly lowers the rates of wound complications, despite its performance in more complex patients with an increased risk of infection. PS-ACS should be performed preferentially over a standard ACS whenever possible.
Background
Wound complications following abdominal wall reconstruction (AWR) in a contaminated setting are common and significantly increase the risk of hernia recurrence. The purpose of this study ...was to examine the effect of short-term negative pressure wound therapy (NPWT) followed by operative delayed primary closure (DPC) of the skin and subcutaneous tissue after AWR in a contaminated setting.
Methods
A prospective institutional hernia database was queried for patients who underwent NPWT-assisted DPC after contaminated AWR between 2008 and 2020. Primary outcomes included wound complication rate and reopening of the incision. A non-DPC group was created using propensity-matching. Standard descriptive statistics were used, and a univariate analysis was performed between the DPC and non-DPC groups.
Results
In total, 110 patients underwent DPC following AWR. The hernias were on average large (188 ± 133.6 cm
2
), often recurrent (81.5%), and 60.5% required a components separation. All patients had CDC Class 3 (14.5%) or 4 (85.5%) wounds and biologic mesh placed. Using CeDAR, the wound complication rate was estimated to be 66.3%. Postoperatively, 26.4% patients developed a wound complication, but only 5.5% patients required reopening of the wound. The rate of recurrence was 5.5% with mean follow-up of 22.6 ± 27.1 months. After propensity-matching, there were 73 patients each in the DPC and non-DPC groups. DPC patients had fewer overall wound complications (23.0% vs 43.9%,
p
= 0.02). While 4.1% of the DPC group required reopening of the incision, 20.5% of patients in the non-DPC required reopening of the incision (
p
= 0.005) with an average time to healing of 150 days. Hernia recurrence remained low overall (2.7% vs 5.4%,
p
= 0.17).
Conclusions
DPC can be performed with a high rate of success in complex, contaminated AWR patients by reducing the rate of wound complications and avoiding prolonged healing times. In patients undergoing AWR in a contaminated setting, a NPWT-assisted DPC should be considered.
Introduction
In complex abdominal wall reconstruction (AWR), the role of concomitant panniculectomy has been debated due to concern for increased wound complications that impact outcomes; however, ...long-term outcomes and quality of life (QOL) have not been well described. The aim of our study was to evaluate the outcomes and QOL in patients undergoing AWR with panniculectomy utilizing 3D volumetric-based propensity match.
Methods
A prospective database from a tertiary referral hernia center was queried for patients undergoing open AWR. 3D CT volumetrics were analyzed and a propensity match comparing AWR patients with and without panniculectomy was created including subcutaneous fat volume (SFV). QOL was analyzed using the Carolinas Comfort Scale.
Results
Propensity match yielded 312 pairs, all with adequate CT imaging for volumetric analysis. The panniculectomy group had a higher BMI (
p
= 0.03) and were more likely female (
p
< 0.0001), but all other demographics and comorbidities were similar. The panniculectomy group was more likely to have undergone prior hernia repair (77% vs 64%,
p
< 0.001), but hernia area, SFV, and CDC wound class were similar (all
p
> 0.05). Requirement of component separation (61% vs 50%,
p
= 0.01) and mesh excision (44% vs 35%,
p
= 0.02) were higher in the panniculectomy group, but operative time were similar (all
p
≥ 0.05). Panniculectomy patients had a higher overall wound occurrence rate (45% vs 32%,
p
= 0.002) which was differentiated only by a higher rate of wound breakdown (24% vs 14%,
p
= 0.003); all other specific wound complications were equal (all
p
≥ 0.05). Hernia recurrence rates were similar (8% vs 9%,
p
= 0.65) with an average follow-up of 28 months. Overall QOL was equal at 2 weeks, and 1, 6, and 12 months (all
p
≥ 0.05).
Conclusions
Despite panniculectomy patients and their hernias being more complex, concomitant panniculectomy increased wound complications but did not negatively impact infection rates or long-term outcomes. Concomitant panniculectomy should be considered in appropriate patients to avoid two procedures.
Introduction
Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for ...emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair.
Methods
A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software.
Results
Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%,
p
= 0.016) and regurgitation (21.9%vs40.2%,
p
= 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%,
p
< 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm
3
,
p
< 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm
2
,
p
< 0.001). In multivariate analysis, HSV increase of 100cm
3
(OR 1.17 CI 1.02–1.35,
p
= 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all
p
< 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (
p
> 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence.
Conclusions
Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.
Background
Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric ...diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution.
Methods
A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed.
Results
180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m
2
(
p
< 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%,
p
= 0.01), but similar rates of hypertension (54.5% vs 44.3%,
p
= 0.18, asthma/COPD (25.7% vs 16.5%,
p
= 0.13), diabetes (10.9% vs 10.1%,
p
= 0.87), and hyperlipidemia (29.7% vs 36.7%,
p
= 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min,
p
< 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4,
p
< 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%,
p
= 0.92). The incidence of recurrent reflux symptoms was not significantly different (
p
= 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (
p
= 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m
2
and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days,
p
= 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%,
p
= 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%,
p
= 0.001).
Conclusions
RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.
Background
The merits of laparoscopic (LVHR) and open preperitoneal ventral hernia repair (OPPVHR) have been debated for more than 2 decades. Our aim was to determine peri-operative and long-term ...outcomes in large hernias.
Methods
A prospective, institutional database at a tertiary hernia center was queried for patients undergoing LVHR and OPPVHR. One-to-one propensity score matching was performed for hernia defect size and follow-up.
Results
Three hundred and fifty-two LVHR and OPPVHR patients were identified with defect sizes closely matched between laparoscopic (182.0 ± 110.0 cm
2
) and open repairs (178.3 ± 99.8 cm
2
),
p
= 0.64. LVHR and OPPVHR patients were comparable: mean age 57.2 ± 12.1 vs 56.6 ± 12.0 years (
p
= 0.52), BMI: 32.9 ± 6.6 vs 32.0 ± 7.4 kg/m
2
(
p
= 0.16), diabetes 19.0% vs 19.7% (
p
= 0.87), and smoking history 8.7% vs 23.0% (
p
< 0.001), respectively. OPPVHR had higher number of recurrent hernias (14.2% vs 44.9%,
p
< 0.001), longer operative time (168.1 ± 64.3 vs 186.7 ± 67.7 min,
p
= 0.006), and more components separation (0% vs 20.3%,
p
< 0.001). Mean mesh size was larger (
p
< 0.001) in the open group (634.4 ± 243.4 cm
2
vs 841.8 ± 277.6 cm
2
). The hernia recurrence rates were similar (10.8% vs 9.2%,
p
= 0.62), with average follow-up of 39.3 ± 32.5 vs 40.0 ± 35.0 months (
p
= 0.89). Length of stay was higher in the OVHR cohort (5.4 ± 3.0 vs 6.3 ± 3.6 days,
p
< 0.001), but 30-day readmission rates (4.0% vs 6.4%,
p
= 0.31) were similar. Overall wound infection rate (2.9% vs 8.4%,
p
= 0.03) was higher in the OPPVHR group, but the mesh infection rate was similar between LVHR (1.7%) and OPPVHR (0.6%) (
p
= 0.33). Postoperative pain (41.1% vs 41.4%,
p
= 0.95) and overall QOL based on the Carolinas Comfort Scale at 6 months (
p
= 0.73) and 5-years (
p
= 0.36) were similar.
Conclusion
Laparoscopic and open preperitoneal repair for large ventral hernias have equivalent hernia recurrence rates, postoperative pain, and QOL on long-term follow-up. Patients undergoing OPPVHR were more likely to be recurrent, complex, require components separation, and more likely to develop postoperative wound complications.
Ventral hernias represent the most common complication after abdominal surgery. Loss of domain and/or large ventral hernias in patients are especially challenging for surgeons to manage, but ...preoperative image-guided botulinum toxin injection has emerged as an effective adjunct to abdominal wall surgery. Loss of domain is caused by chronic muscle retraction of the lateral abdominal wall and leads to an irreducible protrusion of abdominal viscera into the hernia sac. Botulinum toxin can be used in the oblique muscles as a chemical component relaxation technique to aid abdominal wall reconstruction. Intramuscular botulinum toxin injection causes functional denervation by blocking neurotransmitter acetylcholine release resulting in flaccid paralysis and elongation of lateral abdominal wall muscles, increasing the rate of fascial closure during abdominal wall reconstruction, and decreasing recurrence rates. In total, 200–300 units of onabotulinumtoxinA (Botox®) or 500 units of abobotulinumtoxinA (Dypsort®) in a 2:1 dilution with normal saline is most commonly used. Botulinum toxin can be injected with ultrasonographic, EMG, or CT guidance. Injection should be performed at least 2 weeks prior to abdominal wall reconstruction, for maximal effect during surgery. At minimum, botulinum toxin should be injected into the external and internal oblique muscles at three separate sites bilaterally for a total of six injections. Although botulinum toxin use for abdominal wall reconstruction is currently not indicated by the Food and Drug Administration, it is safe with only minor complications reported in literature.
Electronic health records (EHRs) are an integral part of the medical system and are used in all aspects of care. Despite multiple advantages of an EHR, concerns exist over the amount of time that ...residents spend on computers rather than in direct patient care. This study aims to quantify the time a general surgery resident spends on the EHR during their training.
Active usage time data from our institution's EHR were extracted for 34 unique general surgery residents from October 2014 to June 2019. Career time on the EHR was calculated and a “work month” was defined as a 4-week period of 80 hours per week.
Carolinas Medical Center, Charlotte, NC.
Total career EHR usage for a general surgery resident was 2512 continuous hours, corresponding to 31.4 work weeks or 7.9 work months. In total, 7133 charts were opened with an average of 20.5 minutes on the EHR per patient chart. Career time spent on specific tasks included: chart review 10.6 work weeks, documentation 10.4 work weeks, and order entry 5.4 work weeks. The total number of orders entered were 57,739 and total number of documents created were 9222. EHR time in all aspects, patient charts opened, documents created, and number of orders entered decreased as postgraduate year increased.
This is the first study quantifying the total time a general surgery resident spends on the EHR during their clinical training. Total EHR time equated to nearly 8 work months. General surgery residents spend considerable time on the EHR and this underscores the importance of implementing methods to improve EHR efficiency and maximize time for clinical training.
Deep learning models with imbalanced data sets are a challenge in the fields of artificial intelligence and surgery. The aim of this study was to develop and compare deep learning models that predict ...rare but devastating postoperative complications after abdominal wall reconstruction.
A prospectively maintained institutional database was used to identify abdominal wall reconstruction patients with preoperative computed tomography scans. Conventional deep learning models were developed using an 8-layer convolutional neural network and a 2-class training system (ie, learns negative and positive outcomes). Conventional deep learning models were compared to deep learning models that were developed using a generative adversarial network anomaly framework, which uses image augmentation and anomaly detection. The primary outcomes were receiver operating characteristic values for predicting mesh infection and pulmonary failure.
Computed tomography scans from 510 patients were used with a total of 10,004 images. Mesh infection and pulmonary failure occurred in 3.7% and 5.6% of patients, respectively. The conventional deep learning models were less effective than generative adversarial network anomaly for predicting mesh infection (receiver operating characteristic 0.61 vs 0.73, P < .01) and pulmonary failure (receiver operating characteristic 0.59 vs 0.70, P < .01). Although the conventional deep learning models had higher accuracies/specificities for predicting mesh infection (0.93 vs 0.78, P < .01/.96 vs .78, P < .01) and pulmonary failure (0.88 vs 0.68, P < .01/.92 vs .67, P < .01), they were substantially compromised by decreased model sensitivity (0.25 vs 0.68, P < .01/.27 vs .73, P < .01).
Compared to conventional deep learning models, generative adversarial network anomaly deep learning models showed improved performance on imbalanced data sets, predominantly by increasing model sensitivity. Understanding patients who are at risk for rare but devastating postoperative complications can improve risk stratification, resource utilization, and the consent process.
Acquired lung hernias typically result from trauma or intra-thoracic surgery is defined as the protrusion of lung parenchyma beyond the anatomic boundaries of the thoracic wall. A 40-year-old woman ...underwent deep inferior epigastric perforator (DIEP) breast reconstruction following her mastectomies. Post-operatively, she returned to the emergency department with severe chest pain, shortness of breath, and localized chest swelling. CT angiography demonstrated intercostal right lung hernia with concern for incarceration. She returned emergently to the operating room. The lung was reduced, but the flap was ultimately determined to be nonviable and was removed. Post-operative course was uneventful and the patient recovered well. Intercostal lung hernia is an uncommon clinical entity that has not previously been described as a complication of DIEP breast reconstruction. Its development is associated with significant morbidity including flap loss in this case. Early recognition of this rare complication is essential to avoid more severe sequelae of tissue ischemia.
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