Michael G. Tecce

Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis

Background. Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure. Methods. A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications. Results. Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03). Conclusion. Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at‐risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.

Use of Computerized Clinical Decision Support Systems to Prevent Venous Thromboembolism in Surgical Patients: A Systematic Review and Meta-analysis

Importance Health care professionals do not adequately stratify risk or provide prophylaxis for venous thromboembolism (VTE) among surgical patients. Computerized clinical decision support systems (CCDSSs) have been implemented to assist clinicians and improve prophylaxis for VTE. Objective To evaluate the effect of implementing CCDSSs on the ordering of VTE prophylaxis and the rates of VTE. Data Sources PubMed, MEDLINE via OVID, EMBASE via OVID, Scopus, Cochrane CENTRAL Register of Controlled Trials, and clinicaltrials.gov were searched in June 2016 for articles published in English from October 15, 1991, to February 16, 2016. A manual search of references from relevant articles was also performed. Study Selection Clinical trials and observational studies among surgical patients comparing CCDSSs with VTE risk stratification and assistance in ordering prophylaxis vs routine care without decision support were included. Of the 188 articles screened, 11 (5.9%) were eligible for meta-analysis. Data Extraction and Synthesis Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Two reviewers extracted data and assessed quality independently. Main Outcomes and Measures Rates of prophylaxis for VTE and VTE events. Random- and fixed-effects models were used to summarize odds ratios and risk ratios. Results Eleven articles (9 prospective cohort trials and 2 retrospective cohort trials) comprising 156 366 individuals (104 241 in the intervention group and 52 125 in the control group) were included. The use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% CI, 1.78-3.10; P < .001) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85; P < .001). Conclusions and Relevance Use of CCDSSs increases the proportion of surgical patients who were prescribed adequate prophylaxis for VTE and correlates with a reduction in VTE events.

Platelet Rich Plasma Augments Adipose-Derived Stem Cell Growth and Differentiation.

Background Adipose-derived stem cells (ASCs) are a powerful tool for cosmetic surgery and regenerative medicine. The use of autologous platelet rich plasma (PRP), particularly in combination with ASC-based therapy, has significantly expanded in recent years. Unfortunately, the mechanisms and optimal dosing responsible for the beneficial effects of PRP remain poorly understood. Here we investigate the effect of PRP on ASC growth and differentiation. Objectives To assess the impact of different PRP feeding and cryopreservation protocols on ASC isolation, expansion, and differentiation. Methods Human PRP was isolated using the Magellan System (Arteriocyte). Fresh PRP (fPRP), flash frozen PRP (ffPRP), and cryopreserved PRP (cPRP) were added to human ASCs isolated from healthy patients. A panel of PRP supplementation protocols was analyzed for ASC adherence, proliferation, and osteogenesis. Results The fresh and cryopreserved PRP groups demonstrated reduced cell adherence compared to control (non-PRP) groups (P < 0.001), while the flash frozen PRP groups showed cell adherence equivalent to or better than controls. After 7 days of growth, ASC populations for fPRP and ffPRP Single Administration protocols were significantly higher than other feeding protocols and controls. This benefit was lost in cPRP groups. Optimized ffPRP protocols showed potential for spontaneous osteogenesis. Conclusions Addition of ffPRP improves initial ASC adherence while a single administration of either fresh or flash frozen PRP without additional cell manipulation significantly augments subsequent ASC proliferation. The potential for spontaneous osteogenic differentiation upon PRP exposure invokes the need for additional molecular studies of PRP activity prior to further expansion to clinical applications.

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.

Increased Lower Extremity Venous Stasis May Contribute to Deep Venous Thrombosis Formation after Microsurgical Breast Reconstruction—An Ultrasonographic Study

Background Despite guideline‐compliant prophylaxis, an increased rate of deep venous thrombosis (DVT) formation has been reported following autologous versus implant‐based breast reconstruction. We hypothesized that tight abdominal fascia closure might decrease lower extremity venous return and promote venous stasis. Methods An observational crossover study of patients who underwent autologous breast reconstruction using transverse rectus abdominis musculocutaneous/deep inferior epigastric artery perforator flaps was conducted. Ultrasonographic measurements of the left common femoral vein (CFV) and right internal jugular vein (IJV) were performed preoperatively, in the postanesthesia care unit, and on postoperative day (POD) 1. Parameters of interest included vessel diameter, circumference, area, and maximum flow velocity. Results Eighteen patients with a mean age and body mass index of 52.7 years (range, 29–76 years) and 31.3 kg/m2 (range, 21.9–43.4 kg/m2) were included, respectively. A 29.8% increase in CFV diameter was observed on POD 1 (p < 0.0001). Similarly, a 24.3 and 69.9% increase in CFV circumference (p = 0.0007) and area (p < 0.0001) were noted, respectively. These correlated with a 28.4% decrease in maximum flow velocity in the CFV (p = 0.0001). Of note, none of these parameters displayed significant changes for the IJV, thus indicating that observed changes in the CFV were not the result of changes in perioperative fluid status. Conclusion Postoperative changes observed in the CFV reflect increased lower extremity venous stasis after microsurgical breast reconstruction and may contribute to postoperative DVT formation.

Pollicization of Biphalangeal Index Finger for Type IV Thumb Hypoplasia: A Case Report Describing Preoperative Planning, Intraoperative Decision-Making, and Technical Modifications

Background: Index finger (IF) pollicization is the standard treatment for severe congenital thumb hypoplasia. The procedure requires a supple and anatomically normal IF. No guidelines exist for IF pollicization in patients who have concomitantly underdeveloped IF, specifically when the digit has only 2 phalanges and 1 interphalangeal joint. Methods: We present a case of a 20-month-old boy with congenital type IV thumb hypoplasia who also had biphalangeal IF. We proposed an IF pollicization operation that required significant modifications to the traditional procedure. Results: Preoperative planning and intraoperative execution are described. The modifications to the traditional procedure included: (1) removal of proximal third of IF metacarpal; (2) creation of a de novo thumb carpometacarpal (CMC) joint by fibrous union whereby the IF CMC joint cartilaginous components are maintained and the remaining distal IF metacarpal is translocated down and secured to this cartilage (in contrast to the traditional use of IF metacarpophalangeal joint as a de novo thumb CMC joint); (3) preservation of IF joints at their “natural” position and function; (4) maintenance of intrinsic muscles at their original distal insertion sites; and (5) important adjustments to skin incision. Conclusions: Pollicization of biphalangeal IF can be executed in a safe and efficient manner. Early recovery has shown promising signs. Long-term results, including the de novo thumb CMC joint function, remain to be evaluated.

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: Congenital Syndactyly Reconstruction of 391 Webspaces

INtROdUCtION: Congenital syndactyly occurs in isolated and syndromic forms; method of reconstruction must be tailored to the type of syndactyly and postoperative function will depend on the preoperative state of the hand in addition to the method of reconstruction selected. We present the 18 year experience of surgical reconstruction of congenital syndactyly in all of its forms at a high throughput children’s hospital.