Martin J. Carney

Chemical component separation: a systematic review and meta-analysis of botulinum toxin for management of ventral hernia

Abstract Background: Ventral hernia represents a surgical challenge plagued by high morbidity and recurrence rates. Primary closure of challenging hernias is often prohibited by severe lateral retraction and tension of the abdominal wall musculature. Botulinum toxin injections have recently been identified as a potential pre-operative means to counteract abdominal wall tension, reduce hernia size, and facilitate fascial closure during hernia repair. This systematic review and meta-analysis reviews outcomes associated with botulinum toxin injections in the setting of ventral hernia, and demonstrates an opportunity to leverage this mainstream aesthetic product for use in abdominal wall reconstruction. Methods: A literature review was conducted according to PRISMA guidelines using MeSH terms ‘ventral hernia’, ‘herniorrhaphy’, ‘hernia repair’, and ‘botulinum toxins’. Relevant studies reporting pre- and postinjection data were included. Outcomes of interest included changes in hernia defect width and lateral abdominal muscle length, recurrence, complications, and patient follow-up. Qualitative findings were also considered to help demonstrate valuable themes across the literature. Results: Of 133 results, 12 were included for qualitative review and three for quantitative analysis. Meta-analysis revealed significant hernia width reduction (mean = 5.79 cm; n = 29; p < 0.001) and lateral abdominal wall muscular lengthening (mean = 3.33 cm; n = 44; p < 0.001) following botulinum injections. Mean length of follow-up was 24.7 months (range = 9–49). Conclusions: Botulinum toxin injections offer tremendous potential in ventral hernia management by reducing hernia width and lengthening abdominal wall muscles prior to repair. Although further studies are needed, there is a significant opportunity to bridge the knowledge gap in preoperative practice measures for ventral hernia risk reduction.

Application of ARFI-SWV in Stiffness Measurement of the Abdominal Wall Musculature: A Pilot Feasibility Study

The purpose of this study was to assess the feasibility of acoustic radiation force impulse shear wave velocity and textural features for characterizing abdominal wall musculature and to identify subject-related and technique-related factors that can potentially affect measurements. Median shear wave velocity measurements for the right external abdominal oblique were the same (1.89 ± 0.16 m/s) for both the active group (healthy volunteers with active lifestyles) and the control group (age and body mass index-matched volunteers from an ongoing hernia study). When corrected for thickness, the ratio of right external abdominal oblique shear wave velocity -to-muscle thickness was significantly higher in the control group than in the active volunteers (4.33 s-1 versus 2.88 s-1; p value 0.006). From the textural features studied for right external abdominal oblique, 8 features were found to be statistically different between the active and control groups. In conclusion, shear wave velocity is a feasible and reliable technique to evaluate the stiffness of the abdominal wall musculature. Sonographic texture features add additional characterization of abdominal wall musculature.

Patient-Reported Outcomes Following Ventral Hernia Repair: Designing a Qualitative Assessment Tool.

BackgroundCurrent hernia patient-reported outcome (PRO) measures were developed without patient input, greatly impairing their content validity.ObjectiveThe purpose of this study was to develop a conceptual model for PRO measures for ventral hernia (VH) patients.MethodsFifteen semi-structured, concept elicitation interviews and two focus groups employing nominal group technique were conducted with VH patients. Patients were recruited between November 2015 and July 2016 over the telephone from a five-surgeon patient cohort at our institution. Iterative thematic analysis identified domains. Reliability and validation were achieved using inter-rater reliability checks and triangulation.ResultsSeven framework domains were established: (1) expectations; (2) self and others; (3) surgeon and surgical team; (4) sensation; (5) function; (6) appearance; and (7) overall satisfaction. Overall patient satisfaction was associated with two themes: (1) provider–patient relationship; and (2) patient assessment of post-repair improvement.ConclusionsVH patients experience a profoundly broad range of reactions to VH repair. A patient-informed PRO instrument that addresses the spectrum of patient-identified outcomes can guide practice, optimizing care targeting VH patients’ needs.

Abstract 43. 5000 Free Flaps and Counting: 10 Years of a Single Academic Institution’s Microsurgical Experience and A Practical Guide to Developing a Successful Surgical Culture

RESULTS: Answers to questions were highly variable between websites with disparate statements noted, including: 1. 13% of websites state that surgery is required for all craniosynostoses. 2. 14% of websites state that if untreated, craniosynostosis mostly or always leads to developmental delay. 3. 95% of websites state there’s a combined plastic surgical-neurosurgical team approach. 5% are neurosurgeons working alone. 4. 22% of websites only mention open surgical correction. No sites exclusively mention endoscopic techniques. 5. The maximum age for endoscopic surgery is less than 3 months for 50% of sites, 3–6 months by 44%, and 8 months by 6% of websites. 6. 51% of websites obtain CT-scans routinely. 4% of centers do not routinely scan. 44% do not mention CTs 7. 76% of websites do not address if blood transfusion is required. 4% of centers claim transfusion is only required for an open approach.

Abstract P30. Ultrasonic Mapping of the Abdominal Wall using ARFI-SWV: A Prospective Trial to Determine the Physiologic Basis for Reconstruction

PURPOSE: Current indices of risk evaluation for abdominal wall reconstruction focus on thickness and fat measurements, but do not address abdominal wall elasticity and texture assessment. Acoustic-Radiation-Forced-ImpulseShear-Wave-Velocity (ARFI-SWV) is a novel technology to assess skeletal muscle tissue characteristics. This technique has not assessed the abdominal wall physiology for reconstructive patients on a plastic surgery service.

Abstract 14. Should Nerve Coaptation Be Routine? Breast Sensation Following Mastectomy +/- Reconstruction

METHOD: Nationwide Inpatient Sample (2006–2011) was queried to identify bilateral breast reduction cases. Patients with rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s syndrome, Raynaud’s syndrome, psoriatic arthritis, or scleroderma were identified. Demographic factors, comorbidities, and postoperative complications were compared to patients without CTD using student t-test, chi-square, and risk-adjusted multivariate logistic regression.

Abstract 6. The Anatomic Implications of Utilizing Cannula Lipodissection and Avoiding Platysmaplasty in the Tumescent Facelift: A Clinical and Cadaveric Study

Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA, Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Illinois, Chicago IL, USA.

Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience.

Background Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. Methods Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. Results A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: “conservative management,” “excision of mesh with primary closure,” “single-stage reconstruction,” “immediate staged repair,” and “repair in contaminated field.” Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional (“secondary”) repairs after recurrence, 75% were eventually able to achieve “hernia-free” state. Conclusions This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.