Arielle J. Perez

Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair?

IntroductionWhile several patient and operative variables have been shown to be associated with an increased risk of postoperative wound events, the association between surgical hat type worn by surgeons and postoperative wound events remains controversial. The purpose of this study is to investigate the association between type of surgical hat worn by surgeons and the incidence of postoperative wound events following ventral hernia repair using the Americas Hernia Society Quality Collaborative database.MethodsAll surgeons who input at least ten patients with 30-day follow-up into the AHSQC were identified. These surgeons were sent a survey asking them to identify the type of surgical hat they wear in the operating room. The association of the type of surgical hat worn, patient variables, and operative factors with 30-day wound events was investigated using multivariate logistic regression.ResultsA total of 68 surgeons responded to the survey, resulting in 6210 cases available for analysis. The type of surgical hat worn by surgeons was not found to be associated with an increased risk of 30-day surgical site infections or surgical site occurrences requiring procedural intervention.ConclusionOur study is the first study to directly compare the association of surgical hat type with postoperative wound events. There is no association between the type of surgical hat worn and the incidence of postoperative wound events following ventral hernia repair. Our findings suggest that surgical hate type may be chosen at the discretion of operating room personnel without fear of detriment to their patients.

A call for standardization of wound events reporting following ventral hernia repair

IntroductionPostoperative wound events following ventral hernia repair are an important outcome measure. While efforts have been made by hernia surgeons to identify and address risk factors for postoperative wound events following VHR, the definition of these events lacks standardization. Therefore, the purpose of our study was to detail the variability of wound event definitions in recent ventral hernia literature and to propose standardized definitions for postoperative wound events following VHR.MethodsThe top 50 cited ventral hernia, peer-reviewed publications from 1995 through 2015 were identified using the search engine Google Scholar. The definition of wound event used and the incidence of postoperative wound events was recorded for each article. The number of articles that used a standardized definition for surgical site infection (SSI), surgical site occurrence (SSO), or surgical site occurrence requiring procedural intervention (SSOPI) was also identified.ResultsOf the 50 papers evaluated, only nine (18%) used a standardized definition for SSI, SSO, or SSOPI. The papers that used standardized definitions had a smaller variability in the incidence of wound events when compared to one another and their reported rates were more consistent with recently published ventral hernia repair literature.ConclusionPostoperative wound events following VHR are intimately associated with patient quality of life and long-term hernia repair durability. Standardization of the definition of postoperative wound events to include SSI, SSO, and SSOPI following VHR will improve the ability of hernia surgeons to make evidence-based decisions regarding the management of ventral hernias.

Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort.

BackgroundThe advent of newer second-line medical therapies (SLMT) for immune thrombocytopenia (ITP) has contributed to decreased rates of splenectomy, following a trend to avoid or delay surgery. We aimed to characterize the long-term outcomes of laparoscopic splenectomy (LS) for ITP at our institution, examining differences in LS efficiency when performed before or after SLMTs.MethodsAdults with primary ITP who underwent LS between 2002 and 2016 were identified. Retrospective review of electronic medical records was supplemented with telephone interviews. Treatment response was defined according to current guidelines as complete responders (CR), responders (R), and non-responders (NR). Kaplan–Meier estimates assessed relapse-free rates, and predictors of long-term response were investigated using logistic regression.Results109 patients met inclusion criteria, from which 42% were treated with an SLMT before referral to LS. LS was completed in all cases, with no conversions or intraoperative complications. The perioperative morbidity was 7.3%, including 3 deep vein and 2 portal vein thrombosis, one reoperation for bleeding, and no mortalities. Splenectomy was initially effective in 99 patients (CR + R = 90.8%), and 10 patients were NR. At a median 62-month follow-up, 25 patients relapsed, resulting in a 68% CR + R rate. Proportion of CR + R was similar in patients who previously received SLMT and those who did not (61 vs. 76.7%, p = 0.08). CR + R patients were younger (45 vs. 53, p = 0.03), had higher preoperative platelet counts (36 vs. 19, p = 0.01), and experienced a higher increment in platelet counts during hospital stay (117 vs. 38, p < 0.001) as well as 30-days postoperatively (329 vs. 124, p < 0.001). Only a robust response in platelet count at 30-days postoperatively was independently associated with long-term response (OR 1.005, p = 0.006).ConclusionLS was curative in 68% of patients, with no statistically significant difference when performed before or after SLMTs. Outcomes remain challenging to predict preoperatively, with only a robust increase in platelet counts on short term being associated with long-term response.

Effect of transversus abdominis release on core stability: Short-term results from a single institution

Introduction: Transversus abdominis release is an increasingly used procedure in complex abdominal wall reconstruction. The transversus abdominis muscle is a primary stabilizer of the spine, yet little is known regarding the effect of transversus abdominis release on core stability, back pain, or hernia‐specific quality of life. The purpose of our study was to investigate the effect of complex abdominal wall reconstruction using transversus abdominis release on patient quality of life and core stability function. Methods: All patients undergoing complex abdominal wall reconstruction requiring transversus abdominis release from June 2016 through October 2016 at our institution were eligible for study inclusion. Back and hernia quality‐of‐life measures, including the Quebec Back Pain Scale and the Hernia Quality of Life Survey (HerQLes), in addition to patient core stability, as measured using the prone test and the Sahrmann Core Stability Test, were collected at the preoperative evaluation and at 6 months after surgery. Students t test was used to determine the effect of complex abdominal wall reconstruction on quality of life and core stability. Results: Twenty‐one patients completed the preoperative and 6‐month postoperative evaluations. Back pain scores significantly improved postoperatively overall and in each of the 6 subcategories measured using the Quebec Back Pain Scale (P = .001). There was also a statistically significant improvement in abdominal wall function as reflected by Hernia Quality of Life Survey scores (P < .001). There was no statistically significant difference in core stability as reflected in the average prone score (P = .6) or the Sahrmann Core Stability Test average score (P = .4). Conclusion: Abdominal wall reconstruction with transversus abdominis release leads to improved back pain and hernia quality of life and does not appear to negatively affect core stability in the short term.

Immunosuppression is not a risk factor for 30-day wound events or additional 30-day morbidity or mortality after open ventral hernia repair: An analysis of the Americas Hernia Society Quality Collaborative

Background: Some form of immunosuppression is relatively common in patients undergoing ventral hernia repair. Nevertheless, the association of immunosuppression with 30‐day wound events and additional outcomes of morbidity and mortality remains unknown. The purpose of our study was to investigate the association of immunosuppression with 30‐day wound events and additional morbidity and mortality after ventral hernia repair by evaluating the database of the Americas Hernia Society Quality Collaborative. Methods: All patients undergoing open, elective, incisional ventral hernia surgery from July 2013 through April 2017 were identified within the database of the Americas Hernia Society Quality Collaborative. Patients on immunosuppression within the 3 months before operative intervention were compared with patients not on immunosuppression with respect to the incidence of 30‐day wound events, using a 1:5 propensity matched analysis. Results: A total of 3,537 patients met inclusion criteria; 200 (5.7%) patients were on some form of immunosuppression at the time of ventral hernia repair. After propensity matching, 1,200 patients remained for analysis; 200 (16.7%) patients were in the immunosuppression group. There were no statistically significant differences between the 2 groups with respect to the incidence of 30‐day surgical site infection, surgical site occurrence requiring procedural intervention, or additional 30‐day morbidity or mortality outcomes. Patients in the immunosuppression group had a greater rate of surgical site occurrences, the majority of which were seromas (P = .03). Conclusion: Immunosuppression is associated with an increased risk of 30‐day surgical site occurrence but not surgical site infection, surgical site occurrence requiring procedural intervention, or additional 30‐day morbidity or mortality. Additional studies are needed to determine the clinical importance of these surgical site occurrences with respect to long‐term durability of the hernia repair.

Preperitoneal (Stoppa) Open Inguinal Hernia Repair

Open preperitoneal inguinal hernia repair has many advantages and provided the initial foundation for laparoscopic inguinal hernia repair. This approach can be advantageous for large, complicated, and recurrent inguinal hernias. This chapter provides a step-by-step pictorial, with key aspects of the surgical technique required to perform an open preperitoneal, or Stoppa, repair for inguinal hernias.

Hernia repair in patients with chronic liver disease - A 15-year single-center experience

BACKGROUND Elective hernia repairs in chronic liver disease (CLD) patients are often avoided due to the fear of hepatic decompensation and mortality, leaving the patient susceptible to an emergent presentation. METHODS CLD patients undergoing ventral or inguinal hernia repair in emergent and non-emergent settings at our institution (2001-2015) were analyzed. Predictors of 30-day morbidity and mortality (M&M) were determined using univariate analysis and multivariate logistic regression. RESULTS A total of 186 non-emergent repairs identified acceptable rates of M&M (27%) and 90-day mortality (3.7%, 0/21 for MELD≥15). Meanwhile, 67 emergent repairs had higher rates of M&M (60%) and 90-day mortality (10%; 25% for MELD≥15). M&M was associated with elevated MELD scores in emergent cases (14 ± 6 vs 11 ± 4; p = 0.01) and intraoperative drain placement in non-emergent cases (OR1.31,p < 0.01). CONCLUSION In patients with advanced CLD, non-emergent hernia repairs carry acceptable rates of M&M, while emergent repairs have increased M&M rates associated with higher MELD scores.

Peritoneal dialysis catheter placement as a mode of renal replacement therapy: Long-term results from a tertiary academic institution

Background. Peritoneal dialysis as a mode of renal replacement therapy still has not been embraced widely as an alternative to hemodialysis. Furthermore, there is marked variability in peritoneal dialysis catheter insertion techniques and perioperative management within the United States. After the publication of best‐demonstrated practices for peritoneal dialysis catheter placement, the utilization of peritoneal dialysis has increased significantly at our institution. We detail the long‐term success of peritoneal dialysis catheter placement after the adoption of best‐demonstrated practices. Methods. Retrospective chart review was performed on all patients who underwent laparoscopic peritoneal dialysis catheter placement using the best‐demonstrated practice technique from January 2005 through December 2015. Preoperative patient demographic information, intraoperative variables, 30‐day morbidity and mortality, and long‐term catheter durability outcomes were investigated. Results. A total of 457 patients met inclusion criteria. Four (0.9%) patients experienced an immediate postoperative complication requiring return to the operating room. There were no perioperative mortalities. A total of 298 (65.2%) patients were available for long‐term follow‐up; 221 (74.2%) patients are still alive, 76 (25.6%) patients are still undergoing peritoneal dialysis, 63 (21.1%) patients transitioned from peritoneal dialysis to hemodialysis, and 88 (29.5%) patients have undergone kidney transplantation. Based on Kaplan‐Meier survival plots, 30% of patients will transition from peritoneal dialysis to hemodialysis after 5.5 years of peritoneal dialysis and the median time from commencing peritoneal dialysis to kidney transplantation is 5.6 years. Conclusion. Based on our institutional data, the adoption of best‐demonstrated practices should provide long‐term and reliable access to the peritoneal cavity. We recommend the adoption of these techniques to facilitate long‐term peritoneal dialysis catheter survival.