Pieter J. Klitsie

Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair

Chronic pain remains a frequent complication after Lichtenstein inguinal hernia repair. As a consequence, mesh fixation using glue instead of sutures has become popular. This meta‐analysis aimed to clarify which fixation technique is to be preferred for elective Lichtenstein inguinal hernia repair.

Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis.

Open cholecystectomy (OC) is often preferred over laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and portal hypertension, but evidence is lacking to support this practice. This meta‐analysis aimed to clarify which surgical technique is preferable for symptomatic cholecystolithiasis in patients with liver cirrhosis.

Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial

BACKGROUND Incisional hernia is a frequent long-term complication after abdominal surgery, with a prevalence greater than 30% in high-risk groups. The aim of the PRIMA trial was to evaluate the effectiveness of mesh reinforcement in high-risk patients, to prevent incisional hernia. METHODS We did a multicentre, double-blind, randomised controlled trial at 11 hospitals in Austria, Germany, and the Netherlands. We included patients aged 18 years or older who were undergoing elective midline laparotomy and had either an abdominal aortic aneurysm or a body-mass index (BMI) of 27 kg/m2 or higher. We randomly assigned participants using a computer-generated randomisation sequence to one of three treatment groups: primary suture; onlay mesh reinforcement; or sublay mesh reinforcement. The primary endpoint was incidence of incisional hernia during 2 years of follow-up, analysed by intention to treat. Adjusted odds ratios (ORs) were estimated by logistic regression. This trial is registered at ClinicalTrials.gov, number NCT00761475. FINDINGS Between March, 2009, and December, 2012, 498 patients were enrolled to the study, of whom 18 were excluded before randomisation. Therefore, we included 480 patients in the primary analysis: 107 were assigned primary suture only, 188 were allocated onlay mesh reinforcement, and 185 were assigned sublay mesh reinforcement. 92 patients were identified with an incisional hernia, 33 (30%) who were allocated primary suture only, 25 (13%) who were assigned onlay mesh reinforcement, and 34 (18%) who were assigned sublay mesh reinforcement (onlay mesh reinforcement vs primary suture, OR 0·37, 95% CI 0·20-0·69; p=0·0016; sublay mesh reinforcement vs primary suture, 0·55, 0·30-1·00; p=0·05). Seromas were more frequent in patients allocated onlay mesh reinforcement (34 of 188) than in those assigned primary suture (five of 107; p=0·002) or sublay mesh reinforcement (13 of 185; p=0·002). The incidence of wound infection did not differ between treatment groups (14 of 107 primary suture; 25 of 188 onlay mesh reinforcement; and 19 of 185 sublay mesh reinforcement). INTERPRETATION A significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement compared with sublay mesh reinforcement and primary suture only. Onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy. FUNDING Baxter; B Braun Surgical SA.

Calcium score: a new risk factor for colorectal anastomotic leakage.

BACKGROUND Anastomotic leakage (AL) is the most feared complication of colorectal surgery. Atherosclerosis is suggested to have a detrimental effect on anastomotic healing. This study aimed to analyze the calcium score, a measure for atherosclerosis, as a risk factor for AL. STUDY DESIGN The calcium scores of colorectal patients operated on in 2 Dutch university medical centers were determined using a computed tomography scan and calcium scoring software. The aorta, common iliac arteries, internal and external iliac arteries were studied. Additionally, patient- and operation-related factors were scored. RESULTS A total of 122 patients were included. In patients with AL, calcium scores were significantly higher in the left common iliac artery (561.4 vs 156.0, P = .028), right common iliac artery (542.0 vs 144.4, P = .041), both common iliac arteries together (1,103.3 vs 301.9, P = .046), and the left internal iliac artery (716.3 vs 35.3, P = .044). CONCLUSIONS Patients with higher calcium scores in the iliacal arteries have an increased leakage risk.

Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication

BackgroundComplications after thoracic surgery have well been established, pain being the most prominent. Intercostal nerves are mixed type nerves combining motor and sensory functions. This notion is not consistent with the incidence of PTPS compared to the incidence of muscle paresis or paralysis. We would hypothesize that abdominal wall paresis or paralysis is underdiagnosed.MethodsIn our hospital, three patients developed abdominal wall paralysis after thoracic surgery and consequent nerve damage. Their cases are discussed, and a review of the literature was conducted concerning (intercostal) nerve damage on a cellular level, the anatomy of the intercostal nerve, prevention of intercostal nerve damage and surgical techniques.ResultsA cellular cascade known as Wallerian degeneration and regeneration determine whether a damaged nerve can function again. The recovery of the nerve is highly dependent on the correct function of activated Schwann cells and macrophages and is related to the amount of damage that has taken place. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placement during open thoracic surgery has shown to effect compression injury and induced mechanical deformation and damage. Given the known factors of pathophysiology and anatomy, a number of preventive measures have been tested to reduce intercostal nerve damage. Several techniques have been proposed, but the most used technique, the video-assisted thoracic surgery, has been the most effective in reducing nerve damage.ConclusionAbdominal wall paralysis is an underdiagnosed complication after thoracic surgery. The amount of stress on the intercostal nerves could be reduced with less invasive techniques such as the VATS technique.

Anatomy education and classroom versus laparoscopic dissection-based training: a randomized study at one medical school.

Purpose Anatomy education on embalmed specimens is presumed to have added educational value. However, although embalmed specimens have been used for anatomy education for years, there is little evidence on the added educational value of dissection-based teaching. The objective of this randomized study is to examine the added value of dissection-based teaching, using models of the inguinal region in embalmed specimens. Method In 2011, medical students at Erasmus Medical Center, The Netherlands, were randomly assigned to three groups. Group I attended lectures, group II attended dissection-based training using laparoscopic dissection models, and group III attended lectures as well as dissection-based laparoscopic training. To assess the improvement of anatomical knowledge, all students had to complete a practical test before, immediately after, and two weeks after training. Data were analyzed with mixed modeling. Results Forty-six students participated in this study. No significant difference in results was observed among the three groups before the start of training. Immediately after the course, groups II and III scored significantly higher than group I (P < .001; P < .001), and group II scored higher than group III (P = .009). The difference between group I and groups II and III persisted during follow-up (P = 012; P = .001). The difference between groups II and III disappeared. Conclusions Three-dimensional anatomy education with dissection models enhances anatomy learning by medical students. Students who received dissection-based training scored higher in the short- and long term compared with students who did not receive this type of education.

Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomized Controlled Trial

Objective: To compare if watchful waiting is noninferior to elective repair in men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia. Background: The role of watchful waiting in older male patients with mildly symptomatic or asymptomatic inguinal hernia is still not well-established. Methods: In this noninferiority trial, we randomly assigned men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia to either elective inguinal hernia repair or watchful waiting. Primary endpoint was the mean difference in a 4-point pain/discomfort score at 24 months of follow-up. Using a 0.20-point difference as a clinically relevant margin, it was hypothesized that watchful waiting was noninferior to elective repair. Secondary endpoints included quality of life, event-free survival, and crossover rates. Results: Between January 2006 and August 2012, 528 patients were enrolled, of whom 496 met the inclusion criteria: 234 were assigned to elective repair and 262 to watchful waiting. The mean pain/discomfort score at 24 months was 0.35 [95% confidence interval (CI) 0.28–0.41)] in the elective repair group and 0.58 (95% CI 0.52–0.64) in the watchful waiting group. The difference of these means (MD) was −0.23 (95% CI −0.32 to −0.14). In the watchful waiting group, 93 patients (35·4%) eventually underwent elective surgery and 6 patients (2·3%) received emergent surgery for strangulation/incarceration. Postoperative complication rates and recurrence rates in these 99 operated individuals were comparable with individuals originally assigned to the elective repair group (8.1% vs 15.0%; P = 0.106, 7.1% vs 8.9%; P = 0.668, respectively). Conclusions: Our data could not rule out a relevant difference in favor of elective repair with regard to the primary endpoint. Nevertheless, in view of all other findings, we feel that our results justify watchful waiting as a reasonable alternative compared with surgery in men aged 50 years and older.

Incisional hernia after liver transplantation: risk factors and health-related quality of life

The aim of this cross‐sectional study was to analyze the incidence of incisional hernia after liver transplantation (LT), to determine potential risk factors for their development, and to assess their impact on health‐related quality of life (HRQoL). Patients who underwent LT through a J‐shaped incision with a minimum follow‐up of three months were included. Follow‐up was conducted at the outpatient clinic. Short Form 36 (SF‐36) and body image questionnaire (BIQ) were used for the assessment of HRQoL. A total of 140 patients was evaluated. The mean follow‐up period was 33 (SD 20) months. Sixty patients (43%) were diagnosed with an incisional hernia. Multivariate analysis revealed surgical site infection (OR 5.27, p = 0.001), advanced age (OR 1.05, p = 0.003), and prolonged ICU stay (OR 1.54, p = 0.022) to be independent risk factors for development of incisional hernia after LT. Patients with an incisional hernia experienced significantly diminished HRQoL with respect to physical, social, and mental aspects. In conclusion, patients who undergo LT exhibit a high incidence of incisional hernia, which has a considerable impact on HRQoL. Development of incisional hernia was shown to be related to surgical site infection, advanced age, and prolonged ICU stay.

Calcium scoring in unenhanced and enhanced CT data of the aorta-iliacal arteries: Impact of image acquisition, reconstruction, and analysis parameter settings

Background Several studies have been published on the matter of abdominal aortic and iliac calcifications and the association to clinical entities such as diabetes mellitus and renal failure. However, comparing of these studies is questionable since quantification methods for atherosclerosis differ. Purpose To evaluate the effect of image acquisition settings, reconstruction parameters, and analysis methods on calcium quantification in the abdominal aorta. Material and Methods Calcium scores were retrospectively determined on standardized abdominal CT scans of 15 patients. Two researchers obtained calcium scores with 10 different lower thresholds (LT) (130, 145, 160, 175, 200, 300, 400, 500, 600, 1000) in CT scans with and without contrast enhancement, with slice thicknesses (ST) varying between 2.0-5.0 mm for the non-contrast-enhanced series and between 1.0-5.0 mm for the contrast-enhanced series. In addition calcium scores obtained with two convolution kernels (B10f, B20f) were compared. Inter-observer variability was calculated. Results Calcium scoring at higher STs is overestimated compared to smaller STs and this effect was more pronounced with increasing calcium loads. Concerning the convolution kernel, scores obtained with kernel B10f were overestimated compared to kernel B20f. Increase of LT resulted in a decrease of the calcium score and scoring in contrast-enhanced series resulted in higher scores compared to non-contrast-enhanced series. These effects are more apparent in patients with higher calcium loads. Calcium scoring reproducibility with the reference standard is limited for the aorta-iliac trajectory, whereas scoring with the remaining settings is reproducible. Conclusion Scores obtained with different settings cannot be compared. The inter-observer reproducibility was limited using the reference standard and practical difficulties were substantial. Scoring with higher LT, ST, and contrast enhancement is faster and has less practical difficulties.

Laparoscopic umbilical hernia repair in the presence of extensive paraumbilical collateral veins: A case report

A patient with an umbilical hernia presenting with collateral veins in the abdominal wall and umbilicus is a case that every hernia surgeon has to deal with occasionally. Several underlying diseases have been described to provoke collateral veins in the abdominal wall. However, the treatment strategy should be uniform. We herein report a case of a successful laparoscopic umbilical hernia repair in a patient with collateral veins in the abdominal wall and umbilicus. A 63-year-old man was referred to the surgical outpatient clinic with a large symptomatic umbilical hernia and collateral veins in the abdominal wall, secondary to an occlusion of both common iliac veins. Because of collateral veins in the umbilicus and the size of the hernial defect, he was offered laparoscopic hernia repair without compromising these veins. Because of the extensive abdominal wall collaterals, duplex sonography vein mapping was performed preoperatively to mark a safe collateral-free area for trocar introduction. The defect was repaired by mesh prosthesis.