Search

Parastomal hernias are often repaired with mesh to reduce recurrences, but the presence of an ostomy increases the wound class from clean to clean-contaminated/contaminated and makes the choice of mesh more controversial than in a strictly clean case. We aimed to compare the outcomes of biologic and synthetic mesh for parastomal hernia repair.This is a post hoc analysis of parastomal hernia repairs in a randomized trial comparing biologic and synthetic mesh in contaminated ventral hernia repairs. Outcomes included rates of surgical site occurrences requiring procedural intervention (SSOPI), reoperations, stoma/mesh-related adverse events, parastomal hernia recurrence rates (clinical, patient-reported, and radiographic) at 2 years, quality of life (EQ-5D, EQ-5D Visual Analog Scale, and Hernia-Related Quality of Life Survey), and hospital costs up to 30 days.A total of 108 patients underwent parastomal hernia repair (57 biologic [53%] and 51 synthetic [47%]). Demographic and hernia characteristics were similar between the two groups. No significant differences in SSOPI rates or reoperations were observed between mesh types. Four mesh erosions into an ostomy requiring reoperations (2 biologic vs 2 synthetic) occurred. At 2 years, parastomal hernia recurrence rates were similar for biologic and synthetic mesh (17 [29.8%] vs 13 [25.5%], respectively; p = .77). Overall and hernia-related quality of life improved from baseline and were similar between the two groups at 2 years. Median total hospital cost and median mesh cost were higher for biologic compared with synthetic mesh.Biologic and synthetic mesh have similar wound morbidity, reoperations, 2-year hernia recurrence rates, and quality of life in parastomal hernia repairs. Cost should be considered in mesh choice for parastomal hernia repairs.

Background Major abdominal operations often requires postoperative opioid analgesia. However, there is growing recognition of the potential for abuse. We previously reported a significant reduction in opioid consumption after implementation of an Enhanced Recovery after Surgery protocol after ventral hernia repair focusing on opioid reduction. Epidural use was routine for postoperative pain control in this protocol. Recently, we have transitioned to transversus abdominis plane (TAP) block instead of epidural analgesia. We hypothesize that this modification reduces length of stay and lowers opioid use in ventral hernia repair. Methods All patients undergoing open ventral hernia repair were recorded prospectively in the Americas Hernia Society Quality Collaborative database. All patients receiving either TAP or epidural between February 2015 and March 2018 were identified. Additional review was performed to quantify opioid use in morphine milligram equivalents (MMEs). Primary outcomes were length of stay and opioid use. Results Epidural was used in 172 patients and TAP block in 74. There were no significant comorbidity differences between groups. The TAP group had a slightly higher BMI (33.6 kg/m2 vs 28.3 kg/m2) and slightly smaller hernias (8.8 cm vs 10.8 cm). There was no difference in 30-day surgical site infections. Hospital length of stay was significantly shorter with TAP block (2.4 vs 4.5 days; p Conclusions Use of TAP block significantly reduces length of stay and decreases opioid dose requirements in the early postoperative period compared with epidural analgesia.

Mesh repair of incisional hernias has been consistently shown to diminish recurrence rates after repair, with an increased risk of infectious complications. We present a consecutive series of elective, retrorectus mesh repairs of the abdominal wall and attempt to determine predictors of wound events and recurrence.A retrospective review was performed to include elective, retromuscular mesh repairs of complex incisional hernias from August 2006 to August 2013. Demographics, operative details, and postoperative events including wound events, surgical site infections (SSI), and recurrences were recorded.Over the 7-year period, 255 retromuscular mesh repairs of midline incisional defects were performed. Median age of the patients was 58 years, with an average BMI of 32.2 kg/m(2). Average size of the fascial defect was 181.4 cm(2), with recurrent defects making up 48% of repairs. Wound events occurred in 37.7% of cases; SSIs occurred in 19.6% of cases. Recurrence rate was 16.9%, with mean time to recurrence of 19.2 months. With respect to mesh type, recurrences were 16.2% with synthetic, 17.1% for bioabsorbable, and 25% for biologic mesh. When evaluating polypropylene meshes, recurrence was more likely with lightweight mesh (22.9%) vs midweight mesh (10.6%) (p = 0.045). Predictors of SSI included history of mesh infection (odds ratio [OR] 4.8, 95% CI 1.9 to 12.1; p0.001) and recurrent repairs (OR 2.5, 95% CI 1.1 to 5.8; p0.05). The only predictor of recurrence was the presence of an SSI (OR 3.1, 95% CI 1.5 to 6.3; p0.01).Wound events are common after open mesh repairs of complex incisional hernias. Previous mesh infections and recurrent repairs increase the likelihood of an SSI, which significantly increases the risk of recurrence. Recurrences after retrorectus mesh repairs are significantly higher with lightweight compared with mid-weight meshes.

Early readmission after ventral hernia repair (VHR) can hinder patient recovery and increase resource use. The objective of this study was to evaluate the effectiveness of the Americas Hernia Society Quality Collaborative Early Readmission Reduction Initiative in reducing early readmissions after VHR.Risk factors for early readmission and best practices of surgeons with the lowest readmission rates after VHR were determined through collaborative learning. Two interventions for reducing early readmissions were developed: a structured questionnaire administered to patients within 1 week after discharge from the hospital or an early clinic visit after discharge and before a regularly scheduled postoperative visit. Multivariable logistic regression was used to evaluate the impact of these interventions on early readmission.Use of the questionnaire and early clinic visit was tracked in 3,007 patients. Of these, 343 received the questionnaire (2.6% readmission rate), 761 had an early clinic visit after discharge (3.0% readmission rate), 138 had both (4.3% readmission rate), and 1,765 patients received neither (5.9% readmission rate). After controlling for factors associated with early readmissions, administration of the questionnaire (odds ratio 0.42; 95% CI 0.21 to 0.84; p0.05) or having an early clinic visit (odds ratio 0.48; 95% CI 0.30 to 0.76; p 0.05) were both associated with reduced odds for readmission.The Americas Hernia Society Quality Collaborative Early Readmission Reduction Initiative successfully reduced readmissions after VHR using a structured questionnaire or early clinic visit implemented after discharge and before routine 30-day postoperative follow-up.

Background Given the questionable long-term durability of biologic meshes, additional prosthetic options for ventral hernia repairs (VHR) in contaminated fields are necessary. Recent evidence suggests improved bacterial resistance of reduced-weight, large-pore synthetics, giving a potential mesh alternative for repair of contaminated hernias. We aimed to evaluate the clinical outcomes of 2 institutions' experience implanting lightweight polypropylene synthetic mesh in clean-contaminated and contaminated fields. Study Design Open VHRs performed with polypropylene mesh in the retro-rectus position in clean-contaminated and contaminated fields were evaluated. Primary outcomes parameters included surgical site infection, surgical site occurrence, mesh removal, and hernia recurrence. Results One hundred patients (50 male, 50 female) with a mean age of 60 ± 13 years and a mean body mass index (calculated as kg/m 2 ) of 32 ± 9.3 met inclusion criteria. There were 42 clean-contaminated and 58 contaminated cases. The incidence of surgical site occurrence was 26.2% in clean-contaminated cases and 34% in contaminated cases. The 30-day surgical site infection rate was 7.1% for clean-contaminated cases and 19.0% for contaminated cases. There were a total of 7 recurrences with a mean follow-up of 10.8 ± 9.9 months (range 1 to 63 months). Mesh removal was required in 4 patients: 2 due to early anastomotic leaks, 1 due to stomal disruption and retraction in a morbidly obese patient, and 1 from a long-term enterocutaneous fistula. Conclusions Although perhaps not yet considered standard of care in the United States, we have demonstrated favorable infection, recurrence, and mesh removal rates associated with the use of synthetic mesh in contaminated VHR.

Morbidly obese patients undergoing bariatric procedures are at risk for pulmonary embolism (PE). Because large series are required to analyze low-incidence complications, factors predictive of PE have not been clearly defined. Since 1992, short-course heparin prophylaxis, beginning immediately before operation, has been used in this center.Prospective data on 3,861 patients undergoing bariatric procedures between 1980 and 2004 were queried. Factors analyzed included age, gender, body mass index, interval between procedure and PE, inpatient versus outpatient status, mortality, access method (open versus laparoscopic), and comorbidities.PE within 60 days of operation occurred in 33 patients (23 women, 10 men), for an incidence of 0.85%. No difference in incidence was noted between open (0.84%) and laparoscopic (0.88%) groups, nor did routine prophylaxis with heparin since 1992 decrease the incidence. The interval between procedure and PE was 13.2+/-2.6 (mean +/- SEM) days (open=13.0+/-3.0 days, laparoscopic 14.1+/-6.49 days, p=0.9). One-third of PEs occurred after hospital discharge. Pulmonary embolism-related mortality was 27%. A statistically greater body mass index was noted in PE patients compared with non-PE patients (57.2+/-2.4 kg.m(2) versus 49.9+/-0.2 kg/m(2), p0.01, Wilcoxon rank test). Multivariate logistic regression confirmed a primary role for preoperative weight as a predictor of PE; univariate analysis suggested an increased PE risk with obesity hypoventilation syndrome, anastomotic leak, and chronic venous insufficiency.Data demonstrated persistence of PE risk in the anticoagulation, laparoscopic-access era at a rate similar to that in the preanticoagulation, open-access era. Because one-third of PEs occur after hospital discharge, consideration should be given to continuing anticoagulants longer and to adopting a more aggressive policy of inferior vena cava filter prophylaxis, particularly in patients with high body mass index, obese hyperventilation syndrome, and venous insufficiency.

Introduction: Our study purpose was to quantify the effects of diuretics and vasodilators on renal function during hand-assisted laparoscopic donor nephrectomy (HALDN) in a porcine model. Methods: Animals undergoing left HALDN had urine output (UO,mL/Kg/min) and creatinine clearance (CrCl,mL/min) values of each kidney serially measured, independently. Measurements were obtained after 30 minutes of baseline pneumoperitoneum, after renal vessel isolation, after 15 minutes of desufflation, and after 30 minutes of desufflation, following left nephrectomy. Swine (n = 28) were divided into: Group I:no medications. Group II:intravenous mannitol prior to, and furosemide after vessel isolation. Group III:perihilar papaverine-soaked gauze placed for 15 minutes prior to vascular dissection/isolation. Group IV:mannitol, furosemide, and papaverine gauze. Standard statistical methods determined intragroup differences (p Results: Bilateral CrCl decreased during surgery, with no differences between the groups. Only the right kidneys recovered to baseline CrCl after release of pneumoperitoneum. Total UO was lower in the left compared to the right, non-operated kidney in Groups I (0.20 vs 0.31, p=0.003), II (0.65 vs 1.26, p=0.007), III (0.45 vs 0.82, p=0.01), and IV (0.87 vs 1.38, p=0.01). Total UO from the left kidney was greater in the diuretics plus papaverine (0.87) and diuretics alone groups (0.65) compared to papaverine alone (0.45) or control (0.20) (p = 0.0001). A similar observation occurred in the right kidney. Conclusions: Pneumoperitoneum with renal and vascular manipulation impacts renal function of both kidneys during HALDN. Mannitol and furosemide alone, or in combination with papaverine, attenuates these adverse effects, possibly preserving the renal function of both the allograft and contralateral kidney during HALDN.