Ivy N. Haskins

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.

Does Preoperative Bowel Preparation Reduce Surgical Site Infections During Elective Ventral Hernia Repair

BACKGROUND To date, little is known about the benefits of preoperative bowel preparation in patients undergoing elective ventral hernia repair (VHR). The purpose of this study was to determine the effect of preoperative bowel preparation on 30-day wound events in patients undergoing elective VHR using the Americas Hernia Society Quality Collaborative (AHSQC). STUDY DESIGN All patients undergoing elective VHR from January 2013 through January 2016 were identified within the AHSQC. Patients undergoing emergency VHR and those with a CDC wound class IV were excluded from our analysis. Patients were divided into 2 groups: Clean (CDC wound class I) and Contaminated (CDC wound classes II and III). The association of preoperative bowel preparation with 30-day wound events was investigated using logistic regression modeling. RESULTS A total of 3,709 patients met inclusion criteria; 3,101 (83.6%) had CDC wound class I, and 608 (16.4%) had CDC wound classes II or III. Within the Clean group, patients who underwent preoperative bowel preparation were significantly more likely to experience a surgical site infection (SSI), surgical site occurrence (SSO), and surgical site occurrence requiring procedural intervention (SSOPI). Within the Contaminated group, patients who underwent preoperative bowel preparation were significantly more likely to experience an SSOPI. CONCLUSIONS The use of preoperative bowel preparation in patients undergoing elective VHR does not reduce the risk of 30-day wound events.

Inguinal Hernia Recurrence

Inguinal hernia repair is one of the most commonly performed general surgery procedures. Nevertheless, there is currently no consensus regarding the optimal approach to inguinal hernia repair or the management of inguinal hernia recurrence. Herein, we detail the risk factors associated with inguinal hernia recurrence and the operative approaches currently available for recurrent inguinal hernia repair.

How I Do It: Per-Oral Pyloromyotomy (POP)

IntroductionSeveral surgical treatments exist for treatment of gastroparesis, including gastric electrical stimulation, pyloroplasty, and gastrectomy. Division of the pylorus by means of endoscopy, Per-Oral Pyloromyotomy (POP), is a newer, endoluminal therapy that may offer a less invasive, interventional treatment option.MethodsWe describe and present a video of our step by step technique for POP using a lesser curvature approach. The following are technical steps to complete the POP procedure from the lesser curve approach.ConclusionIn our experience, these methods provide promising initial results with low operative risks, although long-term outcomes remain to be determined.

Drain Placement Does Not Increase Infectious Complications After Retromuscular Ventral Hernia Repair with Synthetic Mesh: an AHSQC Analysis

BackgroundThe use of surgical drains after ventral hernia repair (VHR) remains controversial. Some have concerns of increased infectious complications; others advocate that drains reduce fluid accumulation and surgical site occurrences (SSO). The aim of our study was to investigate the impact of retromuscular drains on SSO following retromuscular VHR with synthetic mesh.MethodsUtilizing the Americas Hernia Society Quality Collaborative, patients between January 2013 and January 2016 undergoing retromuscular VHR with synthetic mesh were assessed for the presence of a drain. Propensity score matched patients (2 drains: 1 no drain) were evaluated for 30-day rates of SSO, surgical site infections (SSI) and SSO requiring procedural intervention (SSOPI).ResultsFive hundred eighty-one patients were identified as having undergone open, retromuscular VHR with synthetic mesh. Four hundred eighty-one patients with drains and 100 without drains. After matching, 300 patients were compared, 200 with drain placement and 100 without. Retromuscular drains were less likely to develop a noninfectious SSO (OR, 0.33). Drain placement was not associated with SSI (OR, 1.30) or SSOPI (OR, 0.94).ConclusionDrain placement after retromuscular VHR with synthetic mesh is a common practice. Based on an analysis of early outcomes, surgical drains do not increase the risk of surgical infectious complications, and may be protective against some SSOs, such as seroma formation.

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.

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.

Emergent groin hernia repair: A single center 10-year experience

Background: Emergent groin hernia repair can be a challenging clinical scenario. We aimed to evaluate the perioperative and long‐term outcomes of emergent groin hernia repair at our institution over the last 10 years, with particular interest in surgical approach and mesh use for such cases. Methods: Adult patients who underwent emergent groin hernia repair from 2005–2015 were retrospectively reviewed. Outcomes included surgical site infections, perioperative complications, readmissions, reoperations, mortality, and long‐term hernia recurrence. Predictors of surgical site infection and perioperative complications were investigated using multivariate logistic regression. Results: A total of 257 patients met inclusion criteria (62% males, median age 72). Hernias were most often indirect inguinal (40.9%) and femoral (33.5%), and 45 cases (17.5%) required a bowel resection. Laparoscopic repair was performed in 3 patients (1.2%). Synthetic mesh was placed in 70% of repairs but in only 15% of cases associated with a bowel resection. The medical complications rate was 16.7%; 3.6% had an surgical site infection, and 30‐day mortality rate was 3.1%. Older age (odds ratio 1.05) and gross contamination (odds ratio 4.3) were independently associated with complications. Mesh use was not associated with surgical site infection (odds ratio 1.83, P = .49) or perioperative complications (odds ratio 1.02, P = .96). With a median follow‐up of 43 months, there were no mesh infections and recurrence rates were similar between mesh and tissue repairs (6.3% vs 6.8%, P = .91). Conclusion: Emergent groin hernia repair has high rates of morbidity and mortality most closely associated with increasing age and the presence of contamination. Although mesh use appears to be well tolerated when used in the absence of contamination during emergent groin hernia repair, recurrence rates were similar to tissue repairs.

Component Separation: Options and Techniques

The management of large abdominal wall defects remains clinically challenging. The adoption of the component separation technique has facilitated complex abdominal wall reconstruction with autologous abdominal wall tissue. Herein, we detail the current separation of component techniques as well as the advantages and disadvantages of each surgical technique.