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Parastomal hernias are an inevitable consequence of ostomy formation and their repairs remain a challenge to many surgeons. With multiple systems of classification and a multitude of techniques for hernia repair ranging from suture to mesh repair, the literature remains sparse with regards to the optimal method of repair. The authors describe the most commonly adopted techniques, discuss preventative measures, and review the current literature in the context of perioperative outcomes and hernia recurrence., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Financial/Nonfinancial Disclosures None declared.

Background: Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Nonetheless, some primary care physicians (PCPs) and surgeons from other specialties are reluctant to refer patients for MBS due to safety concerns., Objectives: To compare the outcomes of patients who underwent MBS with those who underwent other common operations., Setting: American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP)., Methods: Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), classified as MBS, were compared to nine frequently performed procedures including hip arthroplasty and laparoscopic cholecystectomy, appendectomy, colectomy, hysterectomy, and hernia repairs, among others. A multivariable logistic regression was constructed to compare outcomes including readmission, reoperation, extended length of stay (ELOS) (>75 th percentile or ≥3 days) and mortality., Results: A total of 1.6 million patients were included, with 11.1% undergoing MBS. The odds of readmission were marginally lower in the cholecystectomy (adjusted odds ratio [aOR] = .88, 95% confidence interval (CI) [.85, .90]) and appendectomy (aOR = .88, 95% CI [.85, .90]) cohorts. Similarly, odds of ELOS were among the lowest, surpassed only by same-day procedures such as cholecystectomies and appendectomies. The MBS group had significantly low odds of mortality, comparable to safe anatomical procedures such as hernia repairs. Infectious and thrombotic complications were exceedingly rare and amongst the lowest after MBS., Conclusions: MBS demonstrates a remarkably promising safety profile and compares favorably to other common procedures in the short-term. PCPs and surgeons from other specialties can confidently refer patients for these low-risk, lifesaving operations., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Symptomatic hiatal hernia (HH) with pouch migration after previous laparoscopic Roux-en-Y gastric bypass (RYGB) is an uncommon complication, with limited extant evidence for the utility of surgical repair., Objective: To evaluate the presentation and resolution of symptoms in patients with HH repair after previous RYGB., Setting: Multicenter University Hospital., Methods: A retrospective review was conducted from 2010 to 2022. Patients with prior RYGB who were undergoing subsequent isolated HH repair were included. Patients undergoing incidental HH repair during concomitant revisional bariatric surgery were excluded. Baseline characteristics and surgical outcomes were evaluated and presented as medians (25th-75th percentile)., Results: Forty-four patients met the inclusion criteria. The time from RYGB to HH repair was 59 months (39-88). Body mass index at HH repair was 31 kg/m 2 (27-39). The most common presenting symptoms of hernia were dysphagia (52%), gastric reflux (39%), and abdominal pain (36%). All HH repairs were completed with a minimally invasive approach (98% laparoscopic, 2% robotic). Nonabsorbable suture was used in 98% of patients, with bioabsorbable mesh in 30%. At a median 28-day (12-117) follow-up, 70% of patients reported full symptom resolution and 23% partial resolution. At follow-up, 2 patients had radiologic HH recurrence, with 1 requiring reoperation., Conclusions: This is the largest series of isolated HH repair for symptomatic pouch migration after previous RYGB. Common presenting symptoms are dysphagia and reflux, and surgical repair yields a high rate of symptom resolution in the short term. Longer follow-up is needed to evaluate the durability of this intervention., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence., Materials and Methods: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI., Results: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model., Conclusion: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH., Competing Interests: Declaration of Competing Interest The authors have no conflicts to report, (Copyright © 2023. Published by Elsevier Ltd.)

Introduction: Ventral wall hernia often causes significant morbidity and requires complex abdominal wall reconstruction (AWR). This study aims to determine whether subcutaneous abdominal fat thickness (AFT) measured with preoperative CT scans could predict postoperative outcomes in patients undergoing AWR., Methods: A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021, with a minimum follow-up of 12 months. Using preoperative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analyzed using statistical tests., Results: The results showed that 9 of 101 patients (8.9%) experienced hernia recurrence. Smoking was associated with an increased risk of hernia recurrence (p < 0.001) with a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus (p < 0.001), and pubic tubercle (p < 0.001) were also associated with hernia recurrence and risk of infection. Only AFT at the pubic tubercle reached significance in the regression model predicting recurrence (OR=1.10; p = 0.030) and infection (OR=1.04; p = 0.021). A cut-off value of 67 mm was associated with a positive predictive value of 42.14% (sensitivity of 67% and specificity of 91%). Hernia defect area was not associated with risk of recurrence or infection., Conclusions: Smoking and increased AFT at the pubic tubercle are significant predictive factors for recurrence and infection in patients undergoing AWR, and preoperative optimization should focus on reducing these factors., Competing Interests: Declaration of Competing Interest MLF, RF, APL, AS, MK, AM, MKZ, DF, PEMB, and SG have nothing to report. All declared interests are outside of the submitted work., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Although the laparoscopic treatment of pediatric inguinal hernia (PIH) has more benefits than traditional surgery, it is difficult to completely avoid the problem of recurrence. The aim of this study was to use a logistic regression model to investigate the causes of recurrence after laparoscopic percutaneous extraperitoneal repair (LPER) of PIH., Patients and Methods: From June 2017 to December 2021, 486 cases of PIH were performed using LPER in our department. We utilized a two-port approach to implement LPER for PIH. All cases were followed up and the recurrent cases were recorded in detail. We used a logistic regression model to analyze the clinical data in order to find the reasons for recurrence., Results: We completed 486 cases with an internal inguinal ostium high ligation using laparoscopic surgery without conversion. Patients were followed for 10-29 months with an average of 18.2 months and 8 cases had recurrent ipsilateral hernia, including 4 recurrent cases in 89 cases (4.49%) using absorbable suture, 1 in 7 cases (14.29%) with internal inguinal ostium larger than 25 mm, 2 in 26 cases (7.69%) with BMI greater than 21, 2 in 41 cases (4.88%) with postoperative chronic constipation. The total recurrence rate was 1.65%. A foreign body reaction occurred in 2 cases, there were no complications such as scrotal hematoma, trocar umbilical hernia and testicular atrophy, and no deaths in this study. Univariate logistic regression analysis showed that patient BMI, ligation suture, diameter of the internal inguinal ostium and postoperative chronic constipation were significant variables (P values 0.093, 0.027, 0.060 and 0.081). The multivariate logistic regression analysis showed that the ligation suture and the diameter of the internal inguinal ostium were the main risk factors for postoperative recurrence, the odds ratio (OR) value were 5.374 and 2.801, the P values 0.018 and 0.046, and the 95% CI were 2.513-11.642 and 1.134-9.125. The area under ROC curve (AUC) for the logistic regression model was 0.735 (the 95% CI 0.677-0.801, P < 0.01)., Conclusion: An LPER for PIH is a safe and effective operation, but there still remains a small probability of recurrence. In order to reduce the recurrence rate of LPER, we should improve surgical skills, choose an appropriate ligature and avoid using LPER for a huge internal inguinal ostium (especially over 25 mm). It is appropriate to be converted to open surgery for the patients with a very wide internal inguinal ostium., Competing Interests: Declaration of competing interest No competing financial interests exist., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

It is still controversial whether glue can be used for mesh fixation in laparoscopic inguinal hernia repair. The aim of this meta-analysis was used to systematically evaluate the effectiveness and safety of glue mesh fixation in laparoscopic tension-free inguinal hernia repair. The PubMed database, EMBASE database and Cochrane Library were searched to collect published randomized controlled trials (RCTs) on laparoscopic tension-free inguinal hernia repair with glue mesh fixation. Sixteen RCTs and 2409 patients with inguinal hernia were included. The meta-analysis showed that compared with the mechanical mesh fixation group(MMFG), the glue mesh fixation group(GMFG) had significantly reduced incidences of chronic pain[relative risk (RR) = 0.40, 95% confidence interval (CI) (0.28,0.57), P < 0.00001], urinary retention[RR = 0.53, 95% CI(0.29,0.97), P = 0.04], haematoma[RR = 0.23, 95% CI(0.09,0.58), P = 0.002] and total complications[RR = 0.28, 95% CI(0.18,0.44), P < 0.00001]; there were no significant differences in pain score on postoperative day 1[MD = -1.33, 95% CI(-2.93,0.26), P = 0.10], operation time[MD = 1.46, 95% CI(-3.97,6.88), P = 0.60] and recurrence rate[RR = 0.72, 95% CI(0.35,1.47), P = 0.37] between the two groups. In conclusion, the application of glue mesh fixation in laparoscopic inguinal hernia repair is safe and reliable with fewer complications. Moreover, it can reduce the incidence of chronic pain without increasing the recurrence rate. However, due to the small number of cases in this analysis and limitations in the quality of the included studies, the findings need to be further verified by multicentre, large-sample and high-quality RCTs in the future., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Management of obstetrical and gynecologic patients with hernias poses challenges to providers. Risks for hernia development include well-described factors that impair surgical wound healing and increase abdominal pressure. Among the diverse populations cared for by obstetricians and gynecologists, pregnant patients and those with gynecologic malignancies are at the highest risk for hernia formation. This article provides an overview of the existing literature, with a focus on patients cared for by obstetrician-gynecologists and commonly encountered preoperative and intraoperative scenarios. We highlight scenarios when a hernia repair is not commonly performed, including those of patients undergoing nonelective surgeries with known or suspected gynecologic cancers. Finally, we offer multidisciplinary recommendations on the timing of elective hernia repair with obstetrical and gynecologic procedures, with attention to the primary surgical procedure, the type of preexisting hernia, and patient characteristics., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Massive ventral hernias pose a challenging reconstructive problem. In comparison to bridging mesh repair, the primary fascial repair is associated with significantly reduced rates of hernia recurrence. This study will review our experience with massive ventral hernia repairs using tissue expansion and anterior component separation as well as present the largest case series to date., Methods: A retrospective review was conducted of 61 patients who underwent abdominal wall tissue expansion prior to herniorrhaphy at a single institution between 2011 and 2017. Demographics, perioperative co-variates, and outcomes were recorded. Univariate and subgroup analysis was performed. Kaplan-Meier survival analysis was used to assess the time to recurrence., Results: Sixty-one patients underwent abdominal wall expansion via tissue expanders (TE). Of these, 56 subsequently underwent staged anterior component separation for attempted closure of large ventral hernia. Major complications of TE placement included TE replacement (4,6.6%), TE leak (2,3.3%), and unplanned readmission (3,4.9%). Higher BMI groups were significantly associated with comorbid hypertension (BMI<30 kg/m 2 , 22.7%; BMI 30-35 kg/m 2 , 68.7%; BMI>35 kg/m 2 , 64.7%; P = 0.004). 15 patients (32.6%) had hernia recurrence and 21 patients (34.4%) still required bridging mesh during herniorrhaphy after tissue expansion., Conclusion: The use of tissue expansion prior to herniorrhaphy can be effective in achieving durable closure for most massive abdominal wall defects - especially those associated with musculofascial, soft tissue, or skin deficiencies. In this proof-of-concept analysis, we found that the efficacy and safety profile of this technique compares favorably to other methods for massive hernia repair in the literature., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest or financial disclosures to report., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Concurrent hernia repair (HR) with abdominal body contouring procedures (ABD), panniculectomy, and abdominoplasty, has been discussed as a strategy. The purpose of this study is to evaluate potential medical and surgical complications following concurrent ABD-HR, with a greater emphasis on cosmetic abdominoplasty., Methods: The 2015-2020 ACS-NSQIP datasets were utilized to identify patients who underwent ABD or ABD-HR. Propensity score (PS) matching was used to reduce selection bias by equating groups (ABD vs. ABD-HR) based on covariates. Bivariate analyses of independent variables by our outcomes of interest were performed using the Pearson Chi-Square and Fisher's Exact tests for categorical variables and the Wilcoxon rank-sum test for continuous variables., Results: Of the 14,115 patients identified in the ACS-NSQIP, 13,634 had ABD, while 481 had both ABD and HR. Following PS-matching of the cohorts, ABD (n = 481) and ABD-HR (n = 481), bivariate analysis of the combination of incisional, umbilical, and epigastric hernias indicated longer operative times (mean: 209.6 min) (P < 0.001) and a longer hospital length of stay (mean: 1.9 days) (P < 0.001). The incidence rate of postoperative complications such as wound dehiscence, deep venous thromboembolism, DVT, unplanned return to the OR within 30 days, and other medical complications revealed no significant differences between the two cohorts. A sub-group analysis of wound complications found no significant difference for any wound type. Analysis was also conducted for each type of hernia separately, yielding the same results., Conclusion: Our results show no increase in postoperative morbidity when combining ABD and HR compared to ABD alone, suggesting that these procedures can be safely performed concurrently and regardless of the type of hernia., Competing Interests: Conflict of interest statement None., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending., Design: We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications., Setting: Tertiary care center, single institution., Participants: Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period., Results: Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09)., Conclusions: Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background/objective: This study aims to understand perspectives on routine pathological examination of hernia sacs following pediatric inguinal hernia and hydrocele repair among Canadian pediatric urologists, surgeons, and pathologists., Study Design: All active members of Pediatric Urologists of Canada (PUC), Canadian Association of Pediatric Surgeons (CAPS), and the divisional heads of anatomical pathology at the Canadian children's hospitals (AP) were invited to participate between June 2019 and January 2021 in an anonymous multiple-choice-based questionnaire., Results: The response rates were 71% from PUC (24/34), 20% from CAPS (25/130), and 64% from AP (7/11). The majority of the surgeons (PUC:54%, CAPS:68%) did not routinely send hernia sacs for pathological examination after inguinal hernia repair. Most felt there was a little value in such examination (PUC:96%, CAPS:72%). Among those who submit hernia sacs, the majority did not receive reports that were clinically significant impacting patient management (PUC:82%, CAPS:50%). On the other hand, the pathologists had mixed opinion on the value of examining hernia sacs. Most of them only did gross examination (86%), unless requested by surgeons or concerning features were noted on gross examination. The majority have found clinically meaningful abnormal findings (71%), including vas deferens and portions of the spermatic cord., Discussion: Currently, there are no evidence-based clinical guidelines on pathological assessment of hernia sacs after pediatric inguinal hernia and hydrocele repair. Instead of making it mandatory, future guidelines should highlight specimens that should be submitted for further investigations (e.g., challenging cases where inadvertent surgical injuries might have occurred). Future studies should also address whether patients who may be at higher risk of having clinically significant pathology can be identified pre- or perioperatively to more efficiently triage specimens that would benefit from pathological examination. Limitation of the study includes low response rate from the CAPS members during the COVID-19 pandemic., Conclusions: While most of the pediatric urologists and surgeons felt there is a little value of pathological examination of hernia sacs following inguinal hernia and hydrocele repair, half of the anatomical pathologists felt there is value. Future studies should aim to establish evidence-based clinical guidelines taking stakeholders perspectives into consideration., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: We aimed to evaluate the causes of complications following surgery for inguinal and femoral hernia, using surgical site infection (SSI) and recurrence rate as indicators of outcomes to consider appropriate treatments., Methods: We retrospectively assessed the medical histories of 1,098 patients with adult inguinal and femoral hernias who underwent herniorrhaphy between July 2010 and March 2019. Using SSI and recurrence rate as indicators of outcomes, we statistically assessed the influence of preoperative and operative conditions on surgical outcomes., Results: The occurrence of postoperative SSI was significantly more frequent in patients who experienced a long surgical duration, excessive blood loss, and incarceration; underwent emergency surgery and bowel resection; and in whom no mesh sheet insertion was performed. There was no correlation between mesh use and SSI in cases that did not require emergency incarceration repair. For cases involving hernia incarceration, the use of a mesh sheet was avoided to prevent potential infection, which could explain the high incidence of SSI in cases where mesh was not used. The hernia may have recurred due to technical issues during the procedure, as well as failure to ligate the hernia sac., Conclusions: Selecting the appropriate surgical method for hernia repair may reduce the incidence of SSI. If manual reduction of inguinal hernias is not possible, an appropriate surgical procedure should be determined based on laparoscopic findings in facilities where laparoscopic hernia surgeries are frequently performed. Moreover, in cases without infection and bowel resection, mesh use may be beneficial. Recurrence can be prevented by ligating the hernia sac during surgery and solving relevant technical problems., Competing Interests: Declaration of competing interest None., (Copyright © 2021. Published by Elsevier Taiwan LLC.)

Background/objective: There are many complications of meshes in hernia repair. The aim of this study was to investigate the effects of onlay titanium-coated meshes (TCM) on recurrence, foreign body sensation and chronic pain in ventral hernia repair., Methods: In this retrospective study, 160 patients undergone TCM or polypropylene mesh (PM) surgery for onlay repair of ventral hernia were examined between May 2014 and January 2018 at our center. Patient characteristics, type of hernia, defect size, operative time, follow-up time, surgical site occurrence (infection, seroma and hematoma), recurrence, foreign body sensation and chronic pain were analyzed. Patients were divided into two groups according to mesh used: TCM (titanium group) or PM (polypropylene group)., Results: Out of 160 patients, 63 (32.6%) had TCM and 97 (67.4%) had PM. There was no significant difference between groups in terms of recurrence (p = 0.757). Chronic pain and foreign body sensation were low in the titanium group (p = 0.047 and p = 0.029, respectively), a positive correlation was found between surgical site infection and recurrence (p = 0.020). In the polypropylene group, an increase in defect size was significantly associated with foreign body sensation and chronic pain (p < 0.001 for both comparisons)., Conclusion: In onlay repair of ventral hernia, TCM led to less foreign body sensation and chronic pain then PM. The surgical site infection was associated with recurrence for these meshes. Additionally, the increase in defect size causes a risk for foreign body sensation and chronic pain in repair using PM., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2021. Published by Elsevier Taiwan LLC.)

Background: Hiatal hernia repair is an essential step to reduce the incidence of gastroesophageal acid reflux disease in patients undergoing sleeve gastrectomy. The safety of addition, a hiatal hernia repair to sleeve gastrectomy, is a critical question., Objectives: Our study aimed to assess the safety of concurrent hiatal hernia repair and sleeve gastrectomy based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data., Setting: University health network, United States., Methods: This study was a registry-based analysis. Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 to 2017 were selected for all patients who underwent sleeve gastrectomy with hiatal hernia repair. Propensity score matching (1:1) was used to control for potential confounding., Results: A total of 101,902 patients (50,951 patients matched pairs) were included in the study. The groups were closely matched as intended. Sleeve gastrectomy with hiatal hernia repair, compared with sleeve gastrectomy alone, was associated with similar risks of death (.02% versus .02%; relative risk [RR], 1.50; 95% confidence interval [CI], .61-3.67, P = .503), and higher risk of 30-day readmission (4.01% versus 2.96%; RR, 1.35; 95%CI, 1.27-1.45, P < .001), 30-day reoperation (1.10% versus .77%; RR, 1.42; 95% CI, 1.25-1.61, P < .001), 30-day intervention (1.24% versus .95%; RR, 1.31; 95%CI, 1.16-1.47, P < .001), and 30-day morbidity (1.85% versus 1.47%; RR, 1.25; 95%CI, 1.14-1.38, P < .001)., Conclusions: Sleeve gastrectomy with hiatal hernia repair is relatively safe in the short term with no increase in the risk of mortality. However, this additional procedure slightly increases the risk of readmission, reoperation, and postoperative intervention, as well as morbidity., Competing Interests: Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: To reduce surgical site infections (SSI), many institutions utilize pre-operative antisepsis with chlorhexidine gluconate (CHG) baths and/or wipes. CHG reduces bacterial colonization of the skin, but it is unclear whether this reduces SSI, and current guidelines from the American College of Surgeons, the Centers for Disease Control, and the World Health Organization do not support this practice. There are several factors that increase the risk of SSI in adults, but there is limited understanding of these factors in pediatric patients., Objectives: The primary objectives were to describe the proportion of pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy who develop a postoperative (postop) SSI and to determine whether pre-operative CHG baths/wipes were associated with SSI. The secondary objectives were to identify other factors associated with SSI and to estimate the cost of CHG baths/wipes in this population., Study Design: Pre-operative antisepsis with CHG baths/wipes was implemented at the authors institution in 2006. The authors performed a retrospective cohort study of patients aged 0-18 years undergoing hernia/hydrocele repair and/or orchiopexy by a pediatric urologist at their institution before (2004) and after (2008) the introduction of CHG. The authors compared the proportion of patients with SSI in the no CHG and CHG groups and evaluated for factors associated with SSI. Statistical analysis included Wilcoxon rank-sum test, Chi-squared test, and Fisher's exact test. The cost of CHG baths and wipes was estimated using institutional fees in 2018 US dollars., Results: A total of 543 patients met inclusion criteria, 203 in the no CHG group and 340 in the CHG group. The overall rate of SSI was 0.92%. There was no association between use of CHG and SSI. No patient or peri-operative factors were associated with development of SSI. There were no CHG-associated adverse events. The cost of materials was estimated at $3.29/patient ($1118.60 for 340 cases in 2008) in 2018 US dollars., Discussion: SSI is not common in pediatric patients undergoing hernia/hydrocele repair or orchiopexy. In the present study, pre-operative antisepsis with CHG baths/wipes is not associated with a reduction in SSI and carries additional cost., Conclusions: To the authors knowledge, this is the first study to evaluate the use of pre-operative antisepsis with CHG baths/wipes in an exclusively pediatric population. In the study, CHG baths/wipes add cost with no clear benefit for reducing SSI in pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy., (Copyright © 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objectives: Chronic pain (CP) affects a significant number of patients following hernia repair, ranging from 11 to 54% in the literature. The aim of this study was to assess the prevalence, overall costs, and health care utilization associated with CP after hernia repair., Materials and Methods: A retrospective longitudinal study was performed using the Truven MarketScan® data base to identify patients who develop chronic neuropathic posthernia repair pain from 2001 to 2012. Patients were grouped into CP and No Chronic Pain (No CP) cohorts. Patients were excluded if they 1) were under 18 years of age; 2) had a previous pain diagnosis; 3) had CP diagnosed <90 days after the index hernia repair; 4) had less than one year of follow-up; or 5) had less than one-year baseline record before hernia repair. Patients were grouped into the CP cohort if their CP diagnosis was made within the two years following index hernia repair. Total, outpatient, and pain prescription costs were collected in the period of five years prehernia to nine years posthernia repair. A longitudinal multivariate analysis was used to model the effects of chronic neuropathic posthernia repair pain on total inpatient/outpatient and pain prescription costs., Results: We identified 76,173 patients who underwent hernia repair and met inclusion criteria (CP: n = 14,919, No CP: n = 61,254). There was a trend for increased total inpatient/outpatient and pain prescription costs one-year posthernia repair, when compared to baseline costs for both cohorts. In both cohorts, total inpatient/outpatient costs remained elevated from baseline through nine years posthernia repair, with the CP cohort experiencing significantly higher cumulative median costs (CP: $51,334, No CP: $37,388). The CP diagnosis year was associated with a 1.75-fold increase (p < 0.001) in total inpatient/outpatient costs and a 2.26-fold increase (p < 0.001) in pain prescription costs versus all other years. In the longitudinal analysis, the CP cohort had a 1.14-fold increase (p < 0.001) in total inpatient/outpatient costs and 2.00-fold increase (p < 0.001) in pain prescription costs., Conclusions: Our study demonstrates the prevalence of CP after hernia surgery to be nearly 20%, with significantly increased costs and healthcare resource utilization. While current treatment paradigms are effective for many, there remains a large number of patients that could benefit from an overall approach that includes nonopioid treatments, such as potentially incorporating neurostimulation, for CP that presents posthernia repair., (© 2018 International Neuromodulation Society.)

Cervical spondylotic myelopathy (CSM) can predispose to acute spinal cord injury and post-operative quadriparesis during non-spine procedures, although few accounts of this phenomenon exist within the literature. To the best of our knowledge, there are only 18 cases reported in the literature including ours with spinal cord injury following elective non-spine surgery with undiagnosed CSM. Due to multifactorial pathophysiology, the maintenance of cervical cord neutrality is not sufficient to ensure that these patients will not sustain cord injury intraoperatively as this solely addresses the role of static factors. Vigilance to factors affecting cord perfusion and vascular compromise, such as the mean arterial pressure (MAP), is imperative. Additionally, further studies should evaluate the role of positioning in the myelopathic patient and whether the steep Trendelenburg position, commonly used in robotic surgeries, contributes to spinal cord venous congestion and resultant cord ischemia in these patients given their baseline stenotic canal. This review illustrates the importance of having a heightened awareness of this common degenerative condition in our aging patient population, often a forgotten underlying medical comorbidity., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: In a recent publication, the International Guidelines for Groin Hernia Management by the European Hernia Society (EHS) recognized the need to individualize and tailor the surgical approach for hernia repair. There may be different opportunities for optimization of the surgical technique for surgeons performing open, laparoscopic, or robotic-assisted hernia repair. Robotic-assisted hernia repair is a relatively new minimally invasive surgical approach compared to laparoscopic and open repair. Currently, there is a lack of comparative prospective studies designed to evaluate long-term outcomes of patients undergoing robotic-assisted, laparoscopic, or open hernia repair., Materials & Methods: This manuscript presents an innovative study design with two study cohorts (incisional and inguinal hernia repair) that contain three arms (robotic-assisted, laparoscopic, and open). The trial objective is to collect short-term and long-term outcomes for patients undergoing robotic-assisted, laparoscopic, or open hernia repair. The present publication will discuss the trial design, methods used to ensure consistency in surgeon expertise, and provides strategies to obtain long-term (> 3 months) follow-up data for enrolled patients., Results: One hundred subjects underwent incisional and one hundred underwent inguinal hernia repair at the time of this manuscript. Surgeon experience was analyzed across the three surgical techniques and follow-up compliance was assessed through 1 year. The follow-up completion rates for both study cohorts were >80% for all visits., Conclusions: The innovative trial design helped to improve the quality and quantity of long-term follow-up. More innovative options to improve patient retention may be tested in future trials of similar design., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Paraesophageal hernias (PEH) are common among patients with obesity. Most patients with severe obesity and a PEH will have the PEH repaired at the time of bariatric surgery. However, it is unclear whether there is increased risk when repairing a PEH during bariatric surgery., Objectives: To examine short-term outcomes of patients undergoing bariatric surgery with concurrent PEH repair versus bariatric surgery alone., Setting: Accredited bariatric centers across the United States and Canada., Methods: Patients who underwent bariatric surgery with concurrent PEH repair were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Using a propensity-score matching algorithm, these patients were matched with a cohort who underwent bariatric surgery only, controlling for age, sex, and other co-morbidities. Overall, 30-day incidence of major complications was the primary outcome. Secondary outcomes included mortality, length of operation, reoperations, and readmissions., Results: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database identified 222,320 bariatric procedures without PEH and 42,732 procedures with concurrent PEH repair. With one-to-one propensity score matching, 42,379 pairs were selected. Background characteristics, including age, sex, preoperative body mass index, and preoperative co-morbidities, did not differ statistically between matched cohorts. There was no statistically significant difference in 30-day major complications (3.5% versus 3.4%, P = .317)., Conclusions: Our analysis indicates that the incidence of major complications for bariatric surgery with concurrent PEH repair is similar to bariatric surgery alone. Overall, this study demonstrates the safety of concurrent bariatric surgery and PEH repair., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Small-for-gestational-age (SGA) birth bears an enhanced risk of developing hypertension, obesity, insulin resistance and mental health disorders in later life as a consequence of adaptive processes in utero. Only a small number of studies on pain perception in SGA infants exist. These are indicative of a blunted stress response to pain in SGA newborns., Aim: We initiated a pilot study investigating differences in postoperative pain perception between SGA and appropriate-for-gestational-age (AGA) infants., Methods: Pain and alertness levels of 10 formerly SGA and 14 AGA infants at the age 0.5-2 years were evaluated by the FLACC scale, Steward and Aldrete Scores following hernia repair, reconstructive surgery of hypospadia and orchidopexy. In addition, the postoperative consumption of non-steroidal anti-inflammatory drugs was compared between SGA and AGA., Results: Postoperative pain and alertness levels were not significantly different in SGA and AGA children. We did not observe significant group differences regarding the consumption of non-steroidal anti-inflammatory drugs., Conclusion: While previous studies were suggestive of a suppressed stress response to pain in SGA newborns, these findings did not fully translate into an altered response to pain beyond the newborn age. Further studies in a larger cohort seem necessary to verify this finding., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Umbilical necrosis is a well-known complication of abdominoplasty, the risk of this complication can be increased when an associated umbilical hernia requires further dissection in peri-umbilical region, potentially leading to umbilical devascularisation. Multiple minimally invasive open techniques were described to avoid this problem. The combined approach of abdominoplasty with laparoscopic umbilical hernia repair is one promising solution to avoid devascularising the umbilicus., Methods: A retrospective evaluation of patients who underwent concomitant abdominoplasty with laparoscopic umbilical hernia repair from 2007 to 2017 was carried out. All patients were followed up and evaluated for complications, including the incidence of umbilical skin necrosis., Results: A total of 47 patients were included in this study. The average operative duration was 3.3hours with an average hospital stay of 2.5 days. No cases of postoperative umbilical necrosis were encountered. A mean follow-up period was 2.4 years showed no cases of hernia or rectus abdominis diastasis recurrence. Minor complications included 4 cases of dehiscence, one hematoma. There was no major complications., Conclusion: The concomitant use of laparoscopic umbilical hernia repair and abdominoplasty is a feasible approach to reduce the risks of umbilical devascularization. Especially in larger hernias and in patients with higher risk of recurrence., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: Obesity is a risk factor for the development of ventral hernia and increases the risk of recurrence and surgical site infection after hernia repair (HR)., Objectives: We tested the hypothesis that bariatric surgery (BS) before HR would decrease these risks in patients with morbid obesity., Setting: University hospital, France., Methods: We retrospectively compared 2 groups of patients with morbid obesity in a case-matched study; 1 underwent immediate HR surgery (control), and the other initially underwent BS and then HR after weight loss (case). Patients were individually matched at a 2:1 ratio according to defect size (<7 or ≥7 cm), obesity grade (<40 or ≥40 kg/m²), American Society of Anesthesiologists score, sex, smoker status, and presence of chronic obstructive pulmonary disease., Results: From 2000 to 2017, 41 patients underwent BS, in association with herniorrhaphy in 14 cases (34%). Initial body mass index was higher in the BS group (46.7 ± 6.4 versus 42.4 ± 7.2, P < .0001) but had decreased by the time of HR (34.1 ± 6.5 versus 42.3 ± 7.2, P < .0001). Prosthetic HR was performed after 21.5 months (range, 7-87); however, 7 patients did not receive HR at this time due to insufficient weight loss. Postoperative morbidity was similar in the 2 groups. Hospital stay was shorter in the BS group (6.2 ± 2.6 versus 10.7 ± 9.3 d, P = .002). After a median follow-up of 4.6 ± 4.1 years, the recurrence rate was lower in the BS group (2/30, 6.7%) than in the control group (12/50, 24%; P = .048)., Conclusion: For morbidly obese patients with ventral hernia, BS before HR surgery can decrease recurrence without increasing morbidity., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Postoperative hyperglycaemia is common in patients having major surgery and is associated with adverse outcomes. This study aimed to determine whether bacteraemia contributed to postoperative systemic inflammation, and whether increases in the expression of muscle mRNAs and proteins reflecting increased muscle inflammation, atrophy and impaired carbohydrate oxidation were evident at the time of surgery, and both local and distant to the site of trauma, and could be associated with impaired glucoregulation., Methods: Fifteen adult patients without diabetes undergoing major abdominal surgery participated in this observational study set in a university teaching hospital. Arterialised-venous blood samples and muscle biopsies were obtained before and after major elective abdominal surgery, from sites local (rectus abdominis - RA) and remote to the site of surgery (vastus lateralis - VL). The main outcome measures included blood glucose concentrations, gut permeability and changes in expression of muscle mRNAs and proteins linked to inflammation and glucose regulation., Results: Immediately postoperatively, RA demonstrated markedly increased mRNA expression levels of cathepsin-L (7.5-fold, P < 0.05), FOXO1 (10.5-fold, P < 0.05), MAFbx (11.5-fold, P < 0.01), PDK4 (7.8-fold, P < 0.05), TNF-α (16.5-fold, P < 0.05) and IL-6 (1058-fold, P < 0.001). A similar, albeit blunted, response was observed in VL. Surgery also increased expression of proteins linked to inflammation (IL-6; 6-fold, P < 0.01), protein degradation (MAFbx; 4.5-fold, P < 0.5), and blunted carbohydrate oxidation (PDK4; 4-fold, P < 0.05) in RA but not VL. Increased systemic inflammation (TNF-α, P < 0.05; IL-6, P < 0.001), and impaired postoperative glucose tolerance (P < 0.001), but not bacteraemia (although gut permeability was increased significantly, P < 0.05) or increased plasma cortisol, were noted 48 h postoperatively., Conclusions: A systemic postoperative proinflammatory response was accompanied by muscle inflammation and metabolic dysregulation both local and remote to the site of surgery, and was not accompanied by bacteraemia., Clinical Trial Registration: Registered at http://clinicaltrials.gov (NCT01134809)., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Postoperative complication following ventral hernia repair (VHR) is a major clinical and financial burden. Preoperative risk assessment is necessary to minimize adverse outcomes following VHR. This study examines the ability of an independent parameter to predict postoperative morbidity following VHR., Methods: A retrospective analysis of 58 patients who underwent VHR by component separation between January 2009 and December 2013 was performed. Preoperative abdominal CT scans were analyzed to assess sarcopenia. Sarcopenia was determined using the Hounsfield unit average calculation (HUAC), a measure of psoas muscle size and density. Sarcopenia was defined as an HUAC score of less than 19.6 HU calculated using receiver operating characteristic (ROC) analysis and the Youden index. Multivariate analysis was performed to analyze the association of sarcopenia and postoperative complications., Results: Preoperative sarcopenia was associated with an increased risk for postoperative complications (odds ratio [OR] = 5.3; p = 0.04). Preexisting gastrointestinal conditions such as ulcerative colitis or colon cancer were associated with an increased risk for postoperative complications (OR = 5.7; p = 0.05). A significantly higher rate of hernia recurrence (33.3% vs. 10.8% [p = 0.04]) and renal failure (19% vs. 2.7% [p = 0.03]) was noted in patients with sarcopenia when compared to patients without sarcopenia., Conclusions: Sarcopenia is an independent risk factor for postoperative complications in patients who underwent VHR. Assessment of sarcopenia using the HUAC score provides an opportunity for the adjustment of perioperative care plans to minimize postoperative complication rates., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction/background: Metachronous contralateral inguinal hernias (MCH) occur in approximately 10% of pediatric patients following unilateral inguinal hernia repairs (UIHR). Laparoscopic evaluation of the contralateral internal ring is a method of identifying high-risk individuals for prophylactic contralateral exploration and repair., Objective: The objective of this study was to assess variation in utilization of diagnostic laparoscopy, and report costs associated with the evaluation of a contralateral patent processus vaginalis during hernia repair in pediatric hospitals., Study Design: The Pediatric Health Information System database was searched to identify outpatient surgical encounters for pediatric patients with a diagnosis of inguinal hernia during a 1-year period (2014). Records were identified that contained diagnostic codes for unilateral or bilateral inguinal hernia in combination with a procedure code for open hernia repair with or without diagnostic laparoscopy., Results: After exclusions there were 3952 hernia repairs performed at 30 hospitals; median age was 4 years (IQR 1-7), 78.8% were male, and 64.9% Caucasian. Three-quarters (76.7%) had UIHR, 8.6% had unilateral repairs with laparoscopy (UIHRL), 12.2% had bilateral inguinal hernia repairs (BIHR), and 2.4% had bilateral repairs with laparoscopy (BIHRL). Where laparoscopy was used, 78% resulted in a unilateral repair and 22% in a bilateral procedure. The percent of patients undergoing laparoscopy varied from 0 to 57% among hospitals, and 0-100% among surgeons. Pediatric surgeons were more than three times more likely to perform a diagnostic laparoscopy compared with pediatric urologists. Median adjusted costs were $2298 (IQR 1659-2955) for UIHR, $2713 (IQR 1873-3409) for UIHRL, $2752 (IQR 2230-3411) for BIHR, and $2783 (IQR 2233-3453) for BIHRL. Median costs varied over two-fold among hospitals ($1310-4434), and over four-fold among surgeons ($948-5040)., Discussion: Data suggested that <10% of patients with clinically unilateral inguinal hernias developed MCH. A negative diagnostic laparoscopy ensured that 0.9-1.31% developed MCH. However, up to 30% of patients underwent contralateral exploration/repair when diagnostic laparoscopy was used. The current study found increased costs associated with the use of laparoscopy, with considerable variation in costs among surgeons and hospitals. These data elucidate competing financial and clinical consequences associated with the use of diagnostic laparoscopy with clinically unilateral hernias., Conclusions: Variation existed in the use of laparoscopy during inguinal hernia repairs and associated costs within the current sample from children's hospitals in the United States. The additional costs of laparoscopic evaluation must be considered against the clinical utility and therapeutic consequences of identifying individuals with a higher risk of metachronous contralateral inguinal hernia., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Metabolic syndrome (MetS) entails the simultaneous presence of a constellation of dangerous risk factors including obesity, diabetes, hypertension, and dyslipidemia. The prevalence of MetS in Western society continues to rise and implies an elevated risk for surgical complications and/or poor surgical outcomes within the affected population., Objective: To assess the risks and outcomes of multi-morbid patients with MetS undergoing open ventral hernia repair., Setting: Multi-institutional case-control study in the United States., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was sampled for patients undergoing initial open ventral hernia repair from 2012 through 2014 and then stratified into 2 cohorts based on the presence or absence of MetS. Statistical analyses were performed to evaluate preoperative co-morbidities, intraoperative details, and postoperative morbidity and mortality to identify risk factors for adverse outcomes., Results: Mean age (61.0 versus 56.0 yr, P<.001), body mass index (39.2 versus 31.1, P<.001), and prevalence of co-morbidities of multiple organ systems were significantly higher (P<.001) in the MetS cohort compared to control. Patients with MetS received higher American Society of Anesthesiologists classifications (81.0% versus 43.1% class 3 or higher, P<.001), were more likely to require operation as emergency cases (11.4% versus 7.2%, P<.001), required longer operative times (103 versus 87 min, P<.001), had longer hospitalizations (3.5 versus 2.4 d, P<.001), and had more contaminated wounds (15.9% versus 12.0% class 2 or higher, P<.001). Overall, they had more medical (7.5% versus 4.2%, P<.001), and surgical complications (9.7% versus 5.4%, P<.001), experienced more readmissions (8.3% versus 5.7%, P<.001) and reoperations (3.4% versus 2.5%, P<.001), and were at higher risk for eventual death (.8% versus .5%, P=.008)., Conclusions: The presence of MetS is related to a multitude of unfavorable outcomes and increased mortality after open ventral hernia repair compared with a non-MetS control group. MetS is a useful marker for high operative risk in a population that is generally prone to obesity and its associated diseases., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Repair of hernias with loss of domain in obese patients can lead to acute respiratory failure., Objectives: The objective of this study was to analyze preoperative progressive pneumoperitoneum (PPP) in increasing abdominal cavity volume and its impact on respiratory function., Setting: The study was conducted at the University Hospital, State University of Londrina, Brazil, which is a referral center for the treatment of obesity. The patients were hospitalized for the duration of the study., Methods: Sixteen obese patients were evaluated. Computed tomography was used to determine hernia sac volume (HSV) and abdominal cavity volume (ACV). Respiratory function was evaluated by measuring vital capacity and forced expiratory volume in the first second (FEV-1). All data were obtained before PPP, on the day before surgery, and on the second postoperative day. PPP was performed daily with insufflation of CO 2 ., Results: The number of insufflations was 12. The average of total volume inflated was 5.7 L. The HSV was 2953 cm 3 before PPP and 1935 cm 3 after PPP. The average ACV increased from 8898 to 11,317 cm 3 after PPP. The relationship between HSV and ACV was 38.2% before and 16.3% after PPP. There was a favorable improvement in respiratory function with an increase in vital capacity from 1875 to 2760 mL and an increase in FEV-1 from 1060 to 1670 mL after PPP. Respiratory function tests after surgery showed values of 2600 and 1560 mL, respectively, for cavity volume and FEV-1. There were no postoperative respiratory complications., Conclusions: This technique can be used safely in the surgical preparation of obese patients with hernias with loss of domain, reducing the relation between HSV and ACV and avoiding pulmonary complications., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Panniculectomy (PAN) is often performed concurrently with ventral hernia repair (VHR) in the obese patient. However, the effectiveness and safety profile of this common practice are not fully established in part because of paucity of comparative effectiveness studies. In this study, a comparative analysis of early complications, long-term hernia recurrence, and healthcare expenditures between VHR-PAN and VHR-only patients is presented., Methods: From the Healthcare Cost and Utilization Project database, obese patients who underwent VHR with and without concurrent PAN were identified. Multivariate cox proportional-hazards regression modeling was performed to compare outcomes between the two groups., Results: The final cohort included 1013 VHR-PAN and 18,328 VHR-only patients. The VHR-PAN patients experienced a longer adjusted length of hospital stay (6.8 days vs. 5.2 days; p < 0.001), a higher rate of in-hospital adverse events (29.3% vs. 20.7%; AOR = 2.34 [2.01-2.74]), and a higher rate of 30-day readmissions (13.6% vs. 8.1%; AOR = 2.04 [1.69-2.48]). However, the 2-year rate of hernia recurrence was lower in the VHR-PAN group (7.9% vs. 11.3%; AOR = 0.65 [0.51-0.82]). Both groups generated considerable hospital charges ($104,805 VHR-PAN vs. $72,206 VHR-only, p < 0.001)., Conclusion: Performing a concurrent PAN in the obese hernia patient is associated with a higher rate of early complications and greater healthcare expenditures, but overall a substantially lower incidence of 2-year hernia recurrence. The literature review presented here also highlights a substantial need for further comparative effectiveness studies to create the needed framework for evidence-based guidelines., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: We report the long-term outcome analysis of 12 patients who underwent two-stage abdominal wall reconstruction using combined submuscular tissue expansion and anterior components separation (CS) technique., Methods: Outcome measures were (1) the patients were assessed for the presence or absence of recurrence; (2) patient-reported outcomes on physical functioning in relation with the abdominal wall reconstruction were evaluated using the SF 36-item health survey., Results: The mean age, average expansion volume, and mean time expansion were 37.5 years, 1250 cc, and 9.5 weeks, respectively. The average soft tissue deficiency size was 15.5 (width) × 19.5 (length) cm 2 . The average fascial defect was 17 (width) × 21.5 (length) cm 2 . No mesh-assisted technique was required. Primary closure was obtained in all. The average follow-up was 39.6 months. Hernia recurrence was noted in one patient (8.3%). All 12 patients completed the SF 36-item health survey. Moreover, 75% of the patients reported 100%, indicating "Not limited in vigorous activities," and 25% indicated "limited a little." All patients reported 100% "not limited at all" in lifting or carrying groceries, climbing several flights of stairs, climbing one flight of stairs, bending, kneeling, stooping, walking more than a mile, walking several blocks, walking one block, bathing, or dressing., Conclusions: Parietal laxity obtained with tissue expansion increases the possibility of direct closure of the fascial layer, skin, and subcutaneous tissue components. Combined use of tissue expansion and CS may result in favorable long-term outcomes as evidenced by patient-reported physical functioning data and low rate of hernia recurrence., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)