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Purpose: Patients from deprived areas are more likely to experience longer waiting times for elective surgery, be multimorbid, and have inferior outcomes from elective and emergency surgery. This study aims to investigate how surgical outcomes vary by deprivation for patients undergoing elective abdominal wall reconstruction., Methods: A three-centre retrospective cohort study was conducted across three hospitals in North-West England, including patients with complex ventral hernias undergoing abdominal wall reconstruction between 2013 and 2021. Demographic data, comorbidities, and index of multiple deprivation quintiles were recorded., Results: 234 patients (49.6% female), age 57 (SD 13) years, underwent elective abdominal wall reconstruction. Significantly higher unemployment rates were found in the most deprived quintiles (Q1 and Q2). There were more smokers in Q1 and Q2, but no significant deprivation related differences in BMI, diabetes, chronic kidney disease or ischaemic heart disease. There were also higher rates of Clavien-Dindo 1-2 complications in Q1 and Q5, but no difference in the Clavien-Dindo 3-4 outcomes. Patients in Q1 and Q5 had a significantly greater hospital length of stay., Conclusion: The association between deprivation and greater unemployment and smoking rates highlights the potential need for equitable support in patient optimisation. The lack of differences in patient co-morbidities and hernia characteristics could represent the application of standardised operative criteria and thresholds. Further research is needed to better understand the relationship between socioeconomic status, complications, and prolonged hospital length of stay., (© 2024. Crown.)

Purpose: Over the last decade, there has been a rapid rise in the development and refinement of abdominal wall repair (AWR) techniques. Numerous cadaveric AWR training courses have been set up with the goal of helping practicing surgeons learn and incorporate them into their surgical repertoire. Some maybe excellent but their quality and consistency are unknown. The aim of this article is to present a stepwise cadaveric dissection template and checklist to standardize all training on open AWR courses and to help course organizers benchmark the quality of their program., Methods: This article is based on both the authors experience as faculty and course leads of cadaveric AWR courses, and the published anatomical and operative literature. The authors represent the training committee of the European Hernia Society, and the AWR subcommittees of the British Hernia Society and Association of Coloproctology of Great Britain & Ireland., Results: A standardized stepwise approach for the cadaveric training of the most recognized procedures for open AWR, including retrorectus repair, posterior and anterior component separation techniques, is presented. Considerations on delegate selection, pre-course material and testing, course structure, and cadaveric models is also provided., Conclusion: Time and financial resources for surgeons to attend courses to learn and hone the skills required for safe effective AWR is limited. Ideally all courses should deliver up to date consistent training of the highest quality. One step to achieve this is by developing a standardized approach to ensure delegate understanding of the operative steps and key anatomical features., Competing Interests: Declarations. Competing interests: The author has no competing interests to declare that are relevant to the content of this article., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Aim: Incisional herniation (IH) is a frequent complication following midline abdominal closure with significant associated morbidity. Randomized controlled trials have demonstrated that the small bites technique (SBT) and prophylactic mesh augmentation (PMA) may reduce IH compared to mass closure techniques, but data are lacking on their implementation in contemporary surgical practice. This survey aimed to evaluate the use of the SBT and PMA and to identify factors associated with their adoption., Method: Between 22 January 2023 and 16 March 2023, consultant surgeons across the UK were asked to complete a 25-question survey on closure of an elective primary midline incision., Results: Responses were received from 267 of 675 eligible surgeons (39.6%) in 38 NHS Trusts. Respondents were evenly split between tertiary centres (47.6%) and district general hospitals (49.4%). SBT and PMA were used by 19.9% and 3.0% of respondents, respectively. Compared to other techniques, surgeons using the SBT were more likely to close the anterior aponeurotic layer only, use single suture filaments, 2-0 gauge sutures and sharp needle points and routinely dissect abdominal layers to aid closure (all p < 0.001). Attendance at lectures/conferences on SBT (p = 0.043) and basing practice on available evidence (p < 0.001) were independently associated with use of the SBT. The commonest barriers to adopting SBT were a perceived lack of evidence (23.8%) and belief that personal IH rates were low (16.8%)., Conclusion: A minority of UK consultant surgeons have adopted the SBT or PMA. Practice change should be driven by more widespread dissemination of current evidence and procedural information., (© 2024 Association of Coloproctology of Great Britain and Ireland.)

Aim: Use of open abdomen (OA) remains an important life-saving manoeuvre in the management of trauma and the abdominal catastrophe. The National Open Abdomen Audit (NOAA) is an audit project investigating the indications, management, and subsequent outcomes of OA treatment throughout the UK. The aim is to generate a snapshot of practice which will inform the management of future patients and potentially reduce the significant harm that can be associated with OA., Methods and Analysis: NOAA is a collaborative, prospective observational audit recruiting patients from across Great Britain and Ireland. The study will open from July 2023 with rolling recruitment across participating sites. All adult patients who leave theatre with an OA will be included and followed-up for 90 days. The primary objective is to prospectively audit the national variability in the management of the OA. Secondary outcomes include the treatment modality used for OA, indication, outcome of treatment and complications, including mortality and development of intestinal failure. All data will be recorded and managed using the secure REDCap electronic data capture and analysed using Stata (version 16.1). Results will be reported in accordance with the STROBE statement., Conclusion: Results will be used to formulate a practical clinical guideline on when to implement an OA along with a stepwise management plan once initiated to reduce the associated morbidity and mortality. It is hoped that participation in this study will facilitate education of surgeons with a "trickle down" effect on all members of the surgical team and remove variability in the management., (© 2023 Association of Coloproctology of Great Britain and Ireland.)

Aim: The effect of negative pressure wound therapy (NPWT) on the pathogenesis and outcome of enteroatmospheric fistulation (EAF) in the septic open abdomen (OA) is unclear. This study compares the development and outcome of EAF following NPWT with that occurring in the absence of NPWT., Methods: Consecutive patients admitted with EAF following abdominal sepsis at a National Reference Centre for intestinal failure between 01 January 2005 and 31 December 2015 were included in this study. Patients were divided into two groups based on those that had been treated with NPWT and those that had not (non-NPWT) and characteristics of their fistulas compared. Clinical outcomes concerning nutritional autonomy at 4 years and time to fistula development, size of abdominal wall defect and complete fistula closure were compared between groups., Results: A total of 160 patients were admitted with EAF following a septic abdomen (31-NPWT and 129-non-NPWT). Median (range) time taken to fistulation after OA was longer with NPWT (18 [5-113] vs. 8 [2-60] days, p = 0.004); these patients developed a greater number of fistulas (3 [2-21] vs. 2 [1-10], p = 0.01), involving a greater length of small bowel (42.5 [15-100] cm vs. 30 [3.5-170] cm, p = 0.04) than those who did not receive NPWT. Following reconstructive surgery, nutritional autonomy was similar in both groups (77% vs. 72%) and a comparable number of patients were also fistula-free (100% vs. 97%)., Conclusions: Negative pressure wound therapy appears to be associated with more complex and delayed intestinal fistulation, involving a greater length of small intestine in the septic OA. This did not, however, appear to adversely affect the overall outcome of intestinal and abdominal wall reconstruction in this study., (© 2022 Association of Coloproctology of Great Britain and Ireland.)

Aim: There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland., Methods: Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines., Results: All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management., Conclusion: These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Background: Gut integrity is compromised in abdominal sepsis with increased cellular apoptosis and altered barrier permeability. Intestinal epithelial cells (IEC) form a physiochemical barrier that separates the intestinal lumen from the host's internal milieu and is strongly involved in the mucosal inflammatory response and immune response. Recent research indicates the involvement of the stimulator of interferons genes (STING) pathway in uncontrolled inflammation and gut mucosal immune response., Methods: We investigated the role of STING signaling in sepsis and intestinal barrier function using intestinal biopsies from human patients with abdominal sepsis and with an established model of abdominal sepsis in mice., Findings: In human abdominal sepsis, STING expression was elevated in peripheral blood mononuclear cells and intestinal biopsies compared with healthy controls, and the degree of STING expression in the human intestinal lamina propria correlated with the intestinal inflammation in septic patients. Moreover, elevated STING expression was associated with high levels of serum intestinal fatty acid binding protein that served as a marker of enterocyte damage. In mice, the intestinal STING signaling pathway was markedly activated following the induction of sepsis induced by cecal ligation perforation (CLP). STING knockout mice showed an alleviated inflammatory response, attenuated gut permeability, and decreased bacterial translocation. Whereas mice treated with a STING agonist (DMXAA) following CLP developed greater intestinal apoptosis and a more severe systemic inflammatory response. We demonstrated that mitochondrial DNA (mtDNA) was released during sepsis, inducing the intestinal inflammatory response through activating the STING pathway. We finally investigated DNase I administration at 5 hours post CLP surgery, showing that it reduced systemic mtDNA and inflammatory cytokines levels, organ damage, and bacterial translocation, suggesting that inhibition of mtDNA-STING signaling pathway protects against CLP-induced intestinal barrier dysfunction., Interpretation: Our results indicate that the STING signaling pathway can contribute to lethal sepsis by promoting IEC apoptosis and through disrupting the intestinal barrier. Our findings suggest that regulation of the mtDNA-STING pathway may be a promising therapeutic strategy to promote mucosal healing and protect the intestinal barrier in septic patients. FUND: National Natural Science Foundation of China., (Copyright © 2019. Published by Elsevier B.V.)

Background: The National Training Programme for laparoscopic colorectal surgery in England was implemented to ensure training was supervised, structured, safe and effective. Delegates were required to pass a competency assessment (sign-off) before undertaking independent practice. This study described the types of errors identified and associated these errors with competency to progress to independent laparoscopic colorectal practice., Methods: All sign-off submissions from the start of the process in January 2008 until July 2013 were included. Content analysis was used to categorise errors. Bayes factor (BF) was used to measure the impact of individual error on assessment outcome. A smaller BF indicates that an error has stronger associations with unsuccessful assessments. Bayesian network was employed to graphically represent the reasoning process whereby the chance of successful assessment diminished with the identification of each error. Quality of the error feedback was measured by the area under the ROC curve which linked the predictions from the Bayesian model to the expert verdict., Results: Among 370 assessments analysed, 240 passed and 130 failed. On average, 2.5 different types of error were identified in each assessment. Cases that were more likely to fail had three or more different types of error (χ(2) = 72, p < 0.0001) and demonstrated poorer technical skills (CAT score <2.7, χ(2) = 164, p < 0.0001). Case complexity or right- versus left-sided resection did not have a significant impact. Errors associated with dissection (BF = 0.18), anastomosis (BF = 0.23) and oncological quality (BF = 0.19) were critical determinants of surgical competence, each reducing the odds of pass by at least fourfold. The area under the ROC curve was 0.84., Conclusions: Errors associated with dissection, anastomosis and oncological quality were critical determinants of surgical competency. The detailed error analysis reported in this study can guide the design of future surgical education and clinical training programmes.

Abdominal wall hernias can be challenging and complicated to manage. The techniques to deal with them are evolving rapidly with increasing adaptation and utilization in general surgery.

Key steps in managing patients with enterocutaneous fistulation and an abdominal wall defect include dealing effectively with abdominal sepsis and providing safe and effective nutritional support and skin care, then assessing intestinal and abdominal anatomy, before undertaking reconstructive surgery. The complexity, cost, and morbidity associated with such cases justifies creation of specialized centers in which gastroenterologic, hernia, and plastic surgical expertise, as well as experienced wound and stoma nursing and nutritional and psychological support, can be made available for patients with these challenging problems., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The mechanism by which cigarette smoking promotes atherosclerosis remains unclear but may involve the endothelium and leukocytes. We postulated a direct acute effect of cigarette smoking on the endothelium and granulocytes by measuring granulocyte expression of L-selectin (flow cytometry) and serum L- and E-selectin (ELISA) before and after smoking in 12 smokers with peripheral vascular disease (claudicants) and 12 otherwise healthy controls. Mean (S.D.) granulocyte L-selectin, expressed as mean fluorescence intensity (MFI), increased in a dose-dependent fashion from 3.58+/-0.67 and 3.27+/-0.67 in controls and claudicants, respectively, to 3.77+/-0.75 and 3.49+/-0.79 10 min after smoking two cigarettes (p<0.002), and to 4.11+/-0.95 and 3.67+/-0.88 30 min after four cigarettes (p<0.001). Serum L-selectin was lower in claudicants at all time points throughout the study period compared with controls (p<0.005) but neither serum E- nor L-selectin levels changed following smoking. Smoking led to an increase in granulocyte expression of L-selectin, which may be important in granulocyte/endothelial adhesion and thus related to atherosclerosis. The lower serum L-selectin levels in claudicants, and the absence of a rise in serum adhesion molecules on smoking, suggests consumption by activated endothelial receptors that may be part of a negative feedback mechanism.