B. Tulloh

Smartphone applications (apps) for bariatric surgery.

Sir By 2015, 500million people are projected to own a smartphone (mobile devices with advanced operating system software). Smartphone-associated downloadable applications (apps) are emerging as valuable resources for patients and clinicians in health education and disease monitoring [1, 2]. There are more than 13,000 health care-related apps [3] with predicted annual sector growth of 25 % per annum, over the next 5 years [4]. In parallel, there has been a 761 % rise in the number of bariatric operations performed from 1998 to 2008 [5]. The supply of contemporary smartphone apps in relation to bariatric surgery has not been previously reported. In other specialities, concerns have been reported about the lack of medical professional involvement, unreferenced source content and a paucity of regulation and quality control [6]. This may potentially cause patient harm [7]. Here, we assessed the content, medical professional involvement, commercial links and consumer reviews of weight loss surgery apps, to identify potential opportunities and highlight risks in relation to apps within the field. The five most widely used smartphone app online stores (Google Play, Apple, Blackberry, Samsung and Windows) were searched for the following bariatric surgery-related terms on the 9 March 2013: weight loss surgery, gastric band, gastric sleeve, bariatric surgery, duodenal switch, gastric balloon, gastric bypass, bilio-pancreatic diversion and gastrectomy. Apps which made no reference to these terms in the content overview pages were excluded, as were identical apps repeated in different app store platforms. Searches included both the app store content provided and links to the websites provided by app developers. Eighty-three individual apps relating to bariatric surgery were identified (Figs. 1 and 2; Table 1). Of these apps, the content primarily concerned: patient information (n=50; 60 %), health care worker education (n=10; 12 %), patient discussion forums (n=7; 8 %), weight loss through hypnosis (n=9; 11 %) and miscellaneous apps (n=7; 8 %) (Fig 2). Overall, medical professional involvement was present in 32 (39 %) apps. Commercial interests (app cost or product/surgical practice promotion) were evident in 56 (67 %) apps. Often, authorship and commercial interests were only discernable by searching the publisher’s website. Mean app cost was

Defects and donuts: the importance of the mesh:defect area ratio.

1.19 for patient apps and

Laparoscopic ventral hernia repair.

17.66 for apps aimed at health care workers, whilst 48 (58 %) apps were free. Patient information apps represented the largest group (n=50; 60 %) and were further subcategorised into apps which primarily provided information about: bariatric surgery (n=30; 36 %), post-operative diet (n=4; 5 %), general weight loss information incorporating advice about surgery (n=14; 28 %) and gastric band volume trackers (n=2; 4 %). Many apps integrated multiple functions, such as weight monitoring, calorie counters and gastric band volume trackers, along with general information regarding the operations available. Medical professional/organisation involvement was evident in just 15 (50 %) of the apps focusing on bariatric surgery. Thirty-two apps (64 %) had no consumer reviews, with an average of 3.2 reviews per app. Three (6 %) apps implied evidenced-based content. Links to surgical consultation were available in 10 (20 %) apps. The lack of medical professional involvement or evidencedbased information, links to private surgery and paucity of peer review makes choosing a reliable app challenging for even experienced app consumers. Patients without medical training K. Connor : R. R. W. Brady (*) : B. Tulloh :A. de Beaux Edinburgh Specialist Bariatric Service, Department of Clinical Surgery, Royal Infirmary of Edinburgh, 56 Little France, Edinburgh, Scotland EH16 4BU, UK e-mail: richardbrady@btinternet.com

Laparoscopic partially extraperitoneal (PEP) mesh repair for laterally placed ventral and incisional hernias.

Techniques in laparoscopic ventral and incisional hernia repair (LVIHR) have changed little since Leblanc and Booth published the first series in 1993 [1] and the bridging repair they described is still widely practised today. In the absence of high-quality studies into operative technique, much of current practice is based on expert opinion and one such example is the widespread acceptance that a mesh overlap of 5 cm in all directions is adequate to minimise recurrence. This is not the result of research, but a misinterpretation of Leblanc himself who stated, in a 2003 review of 200 LVIHR, that a 5-cm overlap was better than 3 cm in terms of preventing recurrence [2]. The fact that a greater overlap correlates with reduced recurrence rate has been borne out by clinical experience, recently reported by Leblanc again in a meta-analysis of over 100 studies [3], but the old dogma recommending a 5-cm overlap remains entrenched [4, 5]. Although we are not aware of any experimental data, a strong mathematical argument can be made to show the need for a greater mesh overlap with larger hernias. This requires that the following facts are agreed:

Comment to: Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Pauli EM et al. Hernia 2015; 19: 285–291

Laparoscopic repair of ventral hernias (primary anterior abdominal wall and incisional hernias not including the groin) has become increasingly popular since its description in 19931. The steps of the procedure are easy to describe: insert the camera port well away from the site of the hernia, clear the anterior abdominal wall of adhesions, lay on an intraperitoneal mesh with generous overlap in all directions, then fix it in place with sutures, tacks or glue. The apparent simplicity of the operation and the intuitive appeal of a ‘keyhole’ approach have been the main drivers behind an explosion in the use of this technique. Despite this rapid and widespread uptake, fewer than 1000 patients have been reported in randomized trials comparing laparoscopic with open techniques2. Surgeons new to the technique have been encouraged by these studies, which have consistently reported a lower incidence of wound infection, less postoperative pain, shorter hospital stay and faster return to full activity with laparoscopic repair. Early recurrences are uncommon and generally reflect technical error, but with longer follow-up there is mounting evidence of late recurrences3 resulting from the slow process of mesh migration and/or mesh contracture4,5. Thus, the overall recurrence rate seems no better than with open surgery, and may well be worse. Although postoperative complications are fewer after laparoscopic repair, those that do occur tend to be more serious. A recent study comparing laparoscopic and open methods reported that 23 per cent of complications in the laparoscopic group required surgical correction (compared with 7 per cent in the open group) and that 5 per cent were lifethreatening (compared with none in the open group)6. In addition, a number of case reports have highlighted new complications unique to the laparoscopic approach, including bowel obstruction, visceral erosion and fistula related to the intraperitoneal mesh, and rectus sheath haematoma and cardiac tamponade from tack penetration7. Dense adhesions to the mesh can also compromise the success of subsequent laparoscopic surgery for other conditions. As operative strategies evolve, there remain unanswered questions. Who is suitable? Which mesh should be used, and what size? How best to fix it? Should the defect be closed? Are there medicolegal consequences? Despite a lack of experimental evidence to indicate that patients fare better with laparoscopic repair, there is general agreement that all but the largest and smallest ventral hernias are potentially operable this way. The presence of multiple defects and obesity tips the balance in favour of the laparoscopic approach. For defects less than 2 cm in diameter, some would argue that an open suture repair is adequate, especially if it is achievable under local anaesthetic. For very large defects it is difficult to stop the mesh from bulging into the defect, and there may be inadequate tissue peripherally to which the mesh can be securely fixed8. When intra-abdominal forces exceed fixation strength, the mesh slides progressively into the defect (mesh migration)4,5. Emergency laparoscopic repair is feasible, but current opinion advises against this in the presence of strangulated bowel. Even during an elective repair, although minor small bowel perforations with minimal contamination may be repaired laparoscopically before proceeding as planned, intraoperative faecal soiling mandates abandoning the operation and/or converting to an open procedure9. Cosmesis is often important. From the patient’s point of view, abdominal wall distortion and deformity may be the drivers for surgical repair. Several small laparoscopic incisions may be intuitively more cosmetic than a single large one, but patients with a significant bulge and redundant skin may be better served by an open repair with excision of redundant skin, in some cases extending to a formal abdominoplasty. Most surgeons accept that ‘naked’ polypropylene mesh in the abdominal cavity is no longer acceptable owing to the long-term risk of adhesion formation. These adhesions can be dense and are associated with an increased risk of small bowel resection at any subsequent abdominal surgery, because of difficulty in gaining access to the abdominal cavity10. Newer ‘antiadhesion’ meshes, designed specifically for intraperitoneal use, do result in fewer adhesions11 but cannot be described as ‘non-stick’. The optimal size of mesh remains contentious. A minimum overlap of 5 cm all around the hernia defect has been recommended12, but this is an

Alternate Methods to Components Separation

Laparoscopic mesh repair is becoming an increasingly popular method of ventral and incisional hernia repair. Entrapment neuropathy is a recognised complication when tacks are used to fix the mesh, particularly below the inguinal ligament and laterally in the abdominal wall. We describe a novel method of ventral hernia repair, which employs transabdominal extra-peritoneal dissection to create a pocket for mesh placement with complete avoidance of tacks in the postero-lateral abdominal wall. This technique is particularly useful for incisional hernias arising through old stoma wounds or appendicectomy incisions, and for Spigelian and lumbar hernias..

36th International Congress of the European Hernia Society, Edinburgh

We enjoyed the article by Pauli et al. [1] and accept that posterior component separation with transversus abdominis release (PCS/TAR) successfully addresses recurrent ventral hernias following anterior component separation. Indeed it makes sense that further lateral releases in a different anatomical plane should allow further medial approximation of the rectus muscles to achieve midline closure. However, we are concerned about an underlying implication in this paper that might not be immediately apparent to the wider readership of this journal. Pauli et al. assert that anterior components separation procedure (ACS) is the preferred technique for closure of large abdominal wall defects. We dispute this, as would many UK and European surgeons, for several reasons. First, the ACS procedure is quite destructive of the abdominal wall, and strength in the midline is only obtained at the expense of the lateral zones. Second, seroma and superficial wound breakdown are common owing to the extensive subcutaneous dissection required. Third, even with mesh reinforcement, 1–5 year recurrences in the region of 10 % are reported [2]. Finally, ACS is only applicable to midline defects. More popular in the UK and Europe is the ‘‘Mesh Sandwich’’ or ‘‘Peritoneal Flap’’ hernioplasty, also known as the ‘‘Swinging Door’’ technique in Scandinavia, which has been widely used for many years but only described recently by Beck [3] and Malik et al. [4]. It is essentially a mesh augmentation of the da Silva operation originally described in 1979 [5]. This procedure utilises one half of the hernial sac to close the peritoneal cavity across the fascial gap and the other half to close the fascia anteriorly, with a retromuscular sublay mesh ‘‘sandwiched’’ in between. Because the defect margins are not necessarily brought together it is a low-tension repair and increases abdominal domain. The flaps of sac, comprising attenuated abdominal wall fascia as well as peritoneum, isolate the mesh from both the peritoneal cavity and the subcutaneous space while providing an autologous bed for tissue ingrowth. For the majority of large ventral hernias this operation has several advantages over the ACS procedure. It does not weaken the lateral musculo-aponeurotic layers in any way. It can be used for transverse and oblique as well as paramedian and midline incisions. Unlike the ACS repair it can generally be re-done in the event of recurrence, utilising the new sac and even the old mesh as part of the repair. Best of all, however, it has recently been shown to have the lowest recurrence rate of all with a calculated average annual recurrence rate of only 0.3 % [2]. We are not trying to discredit the ACS procedure. On the contrary, we consider ACS to be an excellent operation. Similarly, the PCS/TAR procedure is also extremely useful and in our experience affords even more medial mobilisation of the recti than the anterior release. However, to compensate for the lateral weakness induced by release of the transversus aponeurosis, a very large piece of mesh extending into the flanks is required which may adversely affect the function of the abdominal wall. These complex and destructive operations are important for the hernia surgeon’s armamentarium but their indications are limited. The peritoneal flap or sandwich repair is This comment refers to the article available at doi:10.1007/s10029014-1331-8.

Authors' reply: Laparoscopic ventral hernia repair (Br J Surg 2012; 99: 1319-1321).

Mesh repair of large ventral or incisional hernias is problematic when primary fascial closure cannot be achieved. Mesh bridging and components separation are useful techniques and adjuncts such as preoperative pneumoperitoneum and parietal Botox-A injections each have a role. This chapter describes an alternate surgical approach to this problem, a modified retromuscular sublay repair in which mesh is positioned between transposed flaps of preserved hernial sac and rectus sheath. The technique is described in detail along with a discussion of indications and procedure-specific postoperative complications.

Pseudo-recurrence following laparoscopic ventral and incisional hernia repair

The congress was scheduled to run for 2 days as usual and the general format was based on that from previous congresses with a mixture of invited speakers, free papers and industry-sponsored satellite sessions. As in Ghent and Gdansk, the congress opened with a session devoted to evidence-based medicine. However, the convenors also wanted to introduce new faces to the international hernia community with the hope of boosting EHS membership and to achieve consensus opinion on a wide range of controversial hernia topics. To do this required a change in the traditional congress structure and involved several new ideas: A. C. de Beaux B. Tulloh (&) Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK e-mail: bruce.tulloh@luht.scot.nhs.uk

The peritoneal flap hernioplasty for repair of large ventral and incisional hernias

Sir We thank Dr Aellen for his comments to our editorial. We note his concerns regarding the risks of laparoscopic ventral hernia repair (LVHR) and feel they are similar to our own. We also support his view that a retromuscular sublay open repair is a good operation, but we must acknowledge that there is little evidence to support the view that it is the preferred operation in the majority of patients. The majority of, although not all, studies comparing the open approach with LVHR report fewer wound complications and mesh infections with the laparoscopic approach, along with a shorter hospital stay and faster return to full activity. These advantages must be weighed up against the shortand long-term risks associated with placing mesh within the peritoneal cavity, well described by Dr Aellen. The medicolegal side is interesting. Although the majority of cases referred to the authors for medicolegal opinions have no case to answer with respect to negligence, what is clear is that the number of cases referred following laparoscopic surgery exceeds that following open surgery, despite open repairs being performed more often than laparoscopic repairs in the UK. Although we are advocates of LVHR in selected patients, with the right mesh and state-of-the-art technique, we make a plea in our editorial for more information, as there remain too many unanswered questions regarding the laparoscopic approach. Information can be gathered by careful audit of our results and combining the results from many centres. We believe the online platform developed by a European working party has much to recommend it in facilitating this end (the platform can be viewed at http://www.eurahs.eu). A. de Beaux and B. Tulloh Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK (e-mail: adebeaux@doctors.org.uk) DOI: 10.1002/bjs.9080