Ciara R. Huntington

Indocyanine Green Historical Context, Current Applications, and Future Considerations

Background. Indocyanine green (ICG) is a dye used in medicine since the mid-1950s for a variety of applications in in cardiology, ophthalmology, and neurosurgery; however, its fluorescent properties have only recently been used in the intraoperative evaluation of tissue perfusion. Method. A literature review was conducted on the characterization and employment of ICG within the medical field. Historical and current context of ICG was examined while also considering implications for its future use. Results. ICG is a relatively nontoxic, unstable compound bound by albumin in the intravascular space until rapid clearance by the liver. It has widespread uses in hepatic, cardiac, and ophthalmologic studies, and its use in analyzing tissue perfusion and identifying sentinel lymph nodes in cancer staging is gaining popularity. Conclusions. ICG has myriad applications and poses low risk to the patient. Its historical uses have contributed to medical knowledge, and it is now undergoing investigation for quantifying tissue perfusion, providing targeted therapies, and intraoperative identification of neurovascular anatomy, ophthalmic structures, and sentinel lymph nodes. New applications of ICG may lead to reduction in postoperative wound-related complications, more effective ophthalmologic procedures, and better detection and treatment of cancer cells.

Computed tomographic measurements predict component separation in ventral hernia repair

BACKGROUND Preoperative imaging with computed tomography (CT) scans can be useful in preoperative planning. We hypothesized that CT measurements of ventral hernia defect size and abdominal wall thickness (AWT) would correlate with postoperative complications and need for complex abdominal wall reconstruction (AWR). MATERIALS AND METHODS Patients who underwent open ventral hernia repair and had preoperative abdominal CT imagining were identified from an institutional hernia-specific surgery outcomes database at our tertiary referral hernia center. Grade III and IV hernias and biologic mesh cases were excluded. CT measures of defect size and AWT were analyzed and correlated to complications and the need for AWR techniques using univariate, multivariate, and principal component (PC) analyses. PC1 and PC2 used five AWT measures, hernia defect width, and body mass index to create a new component variable. RESULTS There were 151 open ventral hernia repairs included in the study. Preoperative findings included 37.7% male; age 55.3 ± 12.5 years; body mass index (BMI) 33.3 ± 7.8 kg/m(2); 60.3% were recurrent hernias with average defect width 8.5 ± 5.0 cm and area 178.3 ± 214 cm(2); AWT at umbilicus 3.5 ± 1.8 cm; and AWT at pubis 7.0 ± 3.2. Component separation was performed in 24.0% of patients and panniculectomy in 34.4%. Wound complications occurred in 13.3% patients, and 2.7% had hernia recurrence. Increasing defect width, length, and area as well as select AWT measurements were associated with increased need for component separation, concomitant panniculectomy, and higher rates of wound and total complications (all P < 0.05). Using multivariate regression, PC1 was associated with wound complications (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.16); PC2 (hernia defect width) was associated with the need for component separation (OR, 1.16; 95% CI, 1.03-1.30). Hernia recurrence was not predicted by AWT or defect size (OR, 1.00; 95%CI, 0.87-1.15). CONCLUSIONS Preoperative CT measurements of hernia defects and AWT predict wound complications and the need for complex AWR techniques. Obtaining preoperative CT imaging should be a consideration in preoperative planning and may help with patient counseling.

Laparoscopic Repair of Flank Hernias

Flank hernias are lateral abdominal wall defects that occur between the 12th rib and iliac crest. While the majority are believed to be primary, a quarter of flank hernias are incisional and traumatic. Flank hernias are usually located within the superior lumbar triangle (Grynfeltt–Lesshaft hernia)—defined by the 12th rib, lateral border of erector spinae muscles, and medial border of internal obliques—or within the inferior lumbar triangle (Petit hernia)—outlined by the edge of latissimus dorsi, external obliques, and the superior edge of the iliac crest. Preoperative workup often includes CT scan and counseling for preventable comorbidities such as smoking or obesity. Decision making regarding surgical approach depends on many similar factors as ventral hernia repair. Laparoscopic flank hernia repair is performed in a 45° semilateral position with flexion at the hip. The repair involves adhesiolysis, mobilization of the colon, and careful dissection to identify and preserve the ureter, iliac vessels, spermatic cord, and pelvic nerves. Mesh is placed to widely overlap the hernia defect, usually extending to the paraspinous and psoas muscles posteriorly. The mesh is secured with transfascial suture, tacks, and sometimes bone anchors. If possible, the primary defect is closed. Small series show that patients undergoing laparoscopic repair return to daily activities faster than open repairs with no difference in recurrence. However, up to 1/3 of patients report pain, mesh sensation, and/or movement limitation at 1 year postoperatively regardless of approach. Careful preoperative counseling and planning is necessary before embarking upon repair of flank hernias.

Management of Adverse Events During Laparoscopic and Robotic Hernia Repair

Over 350,000 ventral hernia repairs are performed annually each year in the United States, accounting for more than

Incarcerated Abdominal Wall Hernias: Tips and Tricks to the Minimally Invasive Approach

3.2 billion in costs. However, when adverse events occur during or following hernia repair, those costs increase dramatically, and patient quality of life is directly impacted. Meticulous surgical technique and judgment is necessary to avoid or reduce the risk of adverse events during hernia repair. Every hernia surgeon must know how to appropriately treat complications when they arise. Herein, this chapter details the management of intraoperative and perioperative adverse events for the Hernia Surgeon.

Anesthetic Considerations in Inguinal Hernia Repair

Abdominal wall hernias are one of the most frequently encountered surgical diagnoses for acute care surgeons, with surgeons in the United States performing more than 360,000 ventral hernia repairs and 770,000 inguinal hernia repairs annually [1]. Inguinal hernias represent the majority of abdominal wall hernias; as many as one in four men and one in 50 women will require an inguinal hernia repair in their lifetime [2, 3]. The incidence of emergent hernia repairs, however, is increasing with an increase from 16.0 repairs per 100,000 person-years in 2001 to 19.2 per 100,000 person-years in 2010, with the majority of these occurring in patients 65 years and older [2]. Women have higher rates of incarcerated femoral hernias, while men have higher rates of emergent inguinal hernia repairs [2, 3]. As the population ages, incisional hernia repairs are also becoming more frequent, with an annual incidence of 23.5 per 100,000 person-years for women and 32.5 per 100,000 person-years for men [2].

Long-Term Quality of Life Outcomes in Laparoscopic and Open Repair of the Flank Hernia: A Prospective, International Study

There are several options for anesthesia when repairing inguinal hernias. Choices depend on technique, minimally invasive versus open and on multiple patient factors. Operative approach and anesthetic of choice varies greatly between regions of the world, and open inguinal hernia repair is the most common approach worldwide: 86 % of hernias are repaired via an open approach in the USA, 96 % in UK, and 99 % in Japan. General anesthesia also appears to be the dominant anesthesia choice in most Western medical centers. In Denmark, 64 % of elective open groin hernia repairs are performed under general anesthetic, 18 % regional anesthetic, and 18 % local anesthetic. However, open inguinal hernia repair under local anesthesia, compared to general anesthesia, is associated with less postoperative nausea and pain, better postoperative quality of life scores, lower overall cost, and is well tolerated by patients. Laparoscopic inguinal hernia repair is recommended for primary hernias, hernias in women, and bilateral hernias, as well as patients with a desire to return to work or activity more quickly or those at risk of wound infections. In those patients who undergo laparoscopic repair, general anesthesia is still the standard. However, laparoscopic hernia repair under local anesthesia, especially via extraperitoneal approach, may be a promising alternative in the future.

Optimal Timing of Surgical Resection After Radiation in Locally Advanced Rectal Adenocarcinoma: An Analysis of the National Cancer Database

RESULTS: Sixty-seven flank hernia repairs, 25 laparoscopic and 42 open, were examined. Patients undergoing laparoscopic vs open repair were similar in age (58.9 vs 61.8 years, p1⁄40.42), BMI (30.2 vs 30.5 kg/m, p1⁄40.78), operative time (97.7 vs 118.1 minutes, p<0.21), and percentage of primary hernias (72.0% vs 76.2%, p<0.70). Open repairs had larger defects (136.0 vs 41.7cm, p<0.068) and longer length of stay (LOS, 5.6 vs 3.0 days, p<0.0012). There were no mesh or wound infections reported in the study population. There was 1 recurrence in each group (3.0% overall). One-year follow-up rates were 84% for laparoscopic and 74% for open; overall mean follow-up was 22.1 months. At 1 year, mesh sensation, pain, and movement limitation were persistent in nearly 30% of patients regardless of operative approach (Table). Overall, of patients endorsing preoperative pain, 56.5% improved, 39.1% stayed the same, and 4.3% worsened by 1 year.