Jerrod N. Keith

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

Objective: To achieve consensus on the best practices in the management of ventral hernias (VH). Background: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. Methods: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. Results: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m2 (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30–50 kg/m2 or HbA1C = 6.5–8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. Conclusions: Although there was consensus, supported by grade A–C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

YouTube is the Most Frequently Used Educational Video Source for Surgical Preparation.

OBJECTIVE The purpose of this study was to evaluate surgical preparation methods of medical students, residents, and faculty with special attention to video usage. DESIGN Following Institutional Review Board approval, anonymous surveys were distributed to participants. Information collected included demographics and surgical preparation methods, focusing on video usage. Participants were questioned regarding frequency and helpfulness of videos, video sources used, and preferred methods between videos, reading, and peer consultation. Statistical analysis was performed using SAS. SETTING Surveys were distributed to participants in the Department of Surgery at the University of Iowa Hospitals and Clinics, a tertiary care center in Iowa City, Iowa. PARTICIPANTS Survey participants included fourth-year medical students pursuing general surgery, general surgery residents, and faculty surgeons in the Department of Surgery. A total of 86 surveys were distributed, and 78 surveys were completed. This included 42 learners (33 residents, 9 fourth-year medical students) and 36 faculty. RESULTS The overall response rate was 91%; 90% of respondents reported using videos for surgical preparation (learners = 95%, faculty = 83%, p = NS). Regarding surgical preparation methods overall, most learners and faculty selected reading (90% versus 78%, p = NS), and fewer respondents reported preferring videos (64% versus 44%, p = NS). Faculty more often use peer consultation (31% versus 50%, p < 0.02). Among respondents who use videos (N = 70), the most used source was YouTube (86%). Learners and faculty use different video sources. Learners use YouTube and Surgical Council on Resident Education (SCORE) Portal more than faculty (YouTube: 95% versus 73%, p < 0.02; SCORE: 25% versus 7%, p < 0.05). Faculty more often use society web pages and commercial videos (society: 67% versus 38%, p < 0.03; commercial: 27% versus 5%, p < 0.02). CONCLUSIONS Most respondents reported using videos to prepare for surgery. YouTube was the preferred source. Posting surgical videos to YouTube may allow for maximal access to learners who are preparing for surgical cases.

Suture, synthetic, or biologic in contaminated ventral hernia repair

BACKGROUND Data are lacking to support the choice between suture, synthetic mesh, or biologic matrix in contaminated ventral hernia repair (VHR). We hypothesize that in contaminated VHR, suture repair is associated with the lowest rate of surgical site infection (SSI). METHODS A multicenter database of all open VHR performed at from 2010-2011 was reviewed. All patients with follow-up of 1 mo and longer were included. The primary outcome was SSI as defined by the Centers for Disease Control and Prevention. The secondary outcome was hernia recurrence (assessed clinically or radiographically). Multivariate analysis (stepwise regression for SSI and Cox proportional hazard model for recurrence) was performed. RESULTS A total of 761 VHR were reviewed for a median (range) follow-up of 15 (1-50) mo: there were 291(38%) suture, 303 (40%) low-density and/or mid-density synthetic mesh, and 167(22%) biologic matrix repair. On univariate analysis, there were differences in the three groups including ethnicity, ASA, body mass index, institution, diabetes, primary versus incisional hernia, wound class, hernia size, prior VHR, fascial release, skin flaps, and acute repair. The unadjusted outcomes for SSI (15.1%; 17.8%; 21.0%; P = 0.280) and recurrence (17.8%; 13.5%; 21.5%; P = 0.074) were not statistically different between groups. On multivariate analysis, biologic matrix was associated with a nonsignificant reduction in both SSI and recurrences, whereas synthetic mesh associated with fewer recurrences compared to suture (hazard ratio = 0.60; P = 0.015) and nonsignificant increase in SSI. CONCLUSIONS Interval estimates favored biologic matrix repair in contaminated VHR; however, these results were not statistically significant. In the absence of higher level evidence, surgeons should carefully balance risk, cost, and benefits in managing contaminated ventral hernia repair.

Sublay versus underlay in open ventral hernia repair

BACKGROUND The ideal location for mesh placement in open ventral hernia repair (OVHR) remains under debate. Current trends lean toward underlay or sublay repair. We hypothesize that in patients undergoing OVHR, sublay versus underlay placement of mesh results in fewer surgical site infections (SSIs) and recurrences. MATERIALS AND METHODS A multi-institution database of all OVHRs performed from 2010 to 2011 was accessed. Patients with mesh placed in the sublay or underlay position and at least 1 mo of follow-up were included. Primary outcome was SSI. Secondary outcome was hernia recurrence. Multivariate analysis was performed using logistic regression for SSI and Cox regression for recurrence. Subgroup analysis of elective, midline ventral incisional hernias was also performed. RESULTS Of 447 patients, 139 (31.1%) had a sublay repair. The unadjusted analysis showed no difference in SSI and lower recurrence using sublay compared with underlay. On multivariate analysis, there was no difference in SSI using sublay compared with underlay (odds ratio 1.5, 95% confidence interval [CI] 0.8-2.8). Recurrence was less common with sublay (hazard ratio 0.4, 95% CI 0.2-0.8). On subgroup analysis of elective, midline incisional hernias only (n = 247), there were more SSIs with sublay compared with underlay repair (28.0% versus 15.1%, P = 0.018); however, there was no difference in major SSI (sublay 9.3% versus underlay 5.8%, P = 0.315). There were fewer recurrences using sublay repair compared with underlay repair (10.7% versus 25.0%, P = 0.010). CONCLUSIONS In this multi-center, risk-adjusted study, sublay repair was associated with fewer recurrences than underlay repair and no difference in SSI. Randomized controlled trials are warranted to validate these findings.

Patient-Reported Social, Psychological, and Urologic Outcomes After Adult Buried Penis Repair

OBJECTIVE To assess changes in hygiene, urination, and sexual activity after surgery for adult-acquired buried penis. MATERIALS AND METHODS The study included men who underwent buried penis repair from 2011 to 2015. Patients were asked pre- and postoperative questions on hygiene, urinary difficulties, sexual difficulties, and difficulties with activities of daily living (modified Post-Bariatric Surgery Quality of Life Questionnaire). Postoperative satisfaction was assessed at a minimum of 6 months. Pre- and postoperative data were compared with chi-squared analyses. RESULTS Of 14 eligible patients, 12 completed postoperative questionnaires. Buried penis repair required debridement of penile skin with split-thickness skin grafting to penis (n = 11; 92%), escutcheonectomy (n = 12; 100%) and abdominoplasty (n = 10; 83%), scrotoplasty (n = 7; 59%), and securing the supra-penile dermis to the pubic dermal or periosteal tissue (n = 12, 100%). The average length of follow-up was 31 months (±20 months). Mean age was 50 (±10.5 years) and mean body mass index was 55 (±13.7 kg/m2). Wound complications (all Clavian Grade 1) occurred in 9 of 12 patients. Patients reported improvement in hygiene (100%), urination (91%), and sexual function (41%); 92% of patients reported they would choose to have the surgery again; and 83% felt that surgery had led to a positive change in their lives. The ability to perform most activities of daily living, as assessed by the Post-Bariatric Surgery Quality of Life Questionnaire, improved significantly. Over 90% of men had lost additional body weight at last clinical follow-up. CONCLUSION Buried penis repair positively impacts social, psychological, and functional outcomes for patients. Wound complications should be expected but are easily managed.

Choosing surgery as a career: Early results of a longitudinal study of medical students

Background: Few studies have explored the factors associated with the preference of medical students to pursue a specific specialty, and even fewer have observed how these preferences and factors change over time. Methods: A longitudinal survey of medical students was administered at the beginning of first year, second year, and clerkships from 2013–2016. Surveys included demographics and factors associated with their choice of specialty. Results: Response rates were 78–94%. Students with mentors and research experience in any specialty were 3.4 times (P < .001) more likely to choose surgery by their third year of medical school. Surgical research experience on the first‐ and second‐year surveys was associated with 39 (P < .001) and 10 times (P < .001) greater odds of preferring surgical specialties on their third‐year survey. Medical students who had a surgery mentor during the first and second years were associated with 4 (P = .024) and 13 times (P < .001) greater odds of preferring surgical specialties on their third‐year survey. Conclusion: Students who begin surgical research during their first year and develop relationships with surgeon mentors during their second year are significantly more likely to maintain an interest in surgical specialties.