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The comparative performance of synthetic and biologic meshes in complex and contaminated abdominal wall repairs remains controversial. Though biologic meshes are generally favoured in contaminated fields, this practice is based on limited data. Standard dictum regarding infected mesh is to either explant it early or pursue aggressive conservation measures depending on mesh position and composition. Explantation is typically morbid, leaving the patient with recurrent hernias and few reconstructive options. We report a case in which a hernia repaired with synthetic mesh recurred and was reconstructed with underlay biologic mesh. Delayed wound hematoma occurred after initiating anticoagulation for late postoperative pulmonary embolism, which became chronically infected. After multiple failed attempts at medical and interventional salvage of the mesh infection, the patient underwent selective explantation of synthetic mesh with conservation of the underlying biological mesh. She recovered completely without recurrent abdominal wall failure at long-term follow-up. We suggest the 'salvageable' characteristics of biologic meshes may allow conservation, rather than explantation, in select cases of infection., The use of synthetic and/or biologic meshes have become standard of care in most abdominal surgeries involving ventral abdominal wall reconstruction. Surgeons have largely abandoned suture repair in favour of [...]

Background: Complex abdominal wall reconstruction technique remains controversial. The use of biologic mesh products is also debated in active infection, sepsis prophylaxis and high-risk patients. Differences in biologic mesh technology and cost remain significant. We aimed to compare the efficacy of 2 commonly used biologic meshes in regards to hernia recurrence at 1 year. Methods: This study was a parallel, dual-arm, double-blind randomized controlled trial involving adult patients undergoing complex abdominal wall reconstruction with a biologic mesh at a quaternary care institution (2017-2020). Patients were randomly assigned to receive Permacol (cross-linked) compared with Strattice (not crosslinked). The main outcome measure was hernia recurrence at 1 or more years following the index repair. Results: We included 94 patients randomized to undergo reconstruction with 1 of 2 commonly used biologic mesh products (mean age 59.4 yr, standard deviation [SD] 9.9; 51% female; body mass index 32.9, SD 6.8). We found no significant differences between the groups (patient comorbidities, hernia recurrence risk factors, hernia size or infection profiles). Hernia recurrence rates (15%) were similar between groups (median 783 days of follow up, interquartile range 119). We found there was significantly less of a need for a component separation technique in the Strattice group (69% v. 87%). All other secondary outcome measures were equivalent between study arms. Multivariate analysis identified hepatic transplantation (odds ratio [OR] 1.94, 95% confidence intervals [CI] 0.33-4.41), active abdominal wall infection (OR 2.01, 95% CI 0.50-7.01), and more than 1 previous hernia repair (OR 2.68, 95% CI 0.41-5.99) as risk factors for subsequent hernia recurrence; however, there was no difference in recurrence factors between patient study groups. Conclusion: Given similar clinical performance between the 2 most commonly used biologic mesh products, the most cost effective mesh should be used in cost-conscious health care systems. Contexte : Les techniques de reconstruction complexe de la paroi abdominale demeurent un sujet controverse. L'utilisation de treillis biologique ne fait pas non plus consensus dans les cas d'infection active et de prophylaxie du sepsis, ni chez les patients a risque eleve. Les differences dans la technologie employee et le cout des divers produits sur le marche demeurent considerables. Nous avons cherche a comparer l'efficacite de 2 treillis biologiques couramment utilises a prevenir la recidive de hernie apres 1 an. Methodes : Le modele d'etude choisi etait un essai clinique randomise a double insu en 2 bras paralleles auquel ont participe des patients qui subissaient une reconstruction complexe de la paroi abdominale a l'aide d'un treillis biologique dans un etablissement de soins quaternaires (de 2017 a 2020). Apres repartition aleatoire, les patients ont recu le treillis Permacol (reticule) ou le treillis Strattice (non reticule). L'indicateur de resultat principal etait la recurrence de hernie 1 an ou plus apres la reconstruction initiale. Resultats : Nous avons inclus 94 patients qui, apres repartition aleatoire, ont subi une reconstruction avec 1 des 2 treillis biologiques couramment utilises ici a l'etude (age moyen 59,4 ans, ecart-type [E.-T.] 9,9, proportion de femmes 51 %, indice de masse corporelle 32,9, E.-T 6,8). Nous n'avons observe aucune difference significative entre les groupes (comorbidite, facteurs de risque de recidive de la hernie, taille de la hernie ou profil infectieux). Les taux de recidive des hernies (15 %) etaient similaires dans les 2 groupes (mediane 783 j post-intervention; ecart interquartile 119). Nous avons observe un besoin moins frequent de la technique de separation des composants dans le groupe (69 % c. 87 %). Tous les autres indicateurs de resultats secondaires etaient comparables dans les 2 bras de l'etude. Selon l'analyse multivariee, la transplantation hepatique (rapport des cotes [RC] 1,94, intervalle de confiance [IC] de 95 % 0,33-4,41), l'infection active de la paroi abdominale (RC 2,01, IC de 95 % 0,50-7,01) et des antecedents de plus d'une chirurgie de la hernie (RC 2,68, IC de 95 % 0,41-5,99) seraient des facteurs de risque de recidive subsequente de la hernie; cependant, aucune difference dans les facteurs de recurrence n'a ete constatee entre les 2 groupes. Conclusion : Compte tenu des resultats cliniques similaires obtenus avec les 2 treillis biologiques les plus couramment utilises, les systemes de sante pour lesquels la rationalisation des couts est importante devraient choisir le produit le plus economique., Incisional hernias after abdominal operations are unfortunately common for patients (up to 23%) and costly to health care systems. (1-6) In patients who pursue surgical repair by way of abdominal [...]

Surgical programs are facing major and fluctuating changes to the resident workforce because of decreased elective volumes and high exposure risk during the coronavirus disease 2019 pandemic. Rapid restructuring of a residency program to protect its workforce while maintaining educational value is imperative. We describe the experience of the Division of General Surgery at the University of Ottawa in Ontario, Canada. The residency program was restructured to feature alternating 'on' and 'off' weeks, maintaining a healthy resident cohort in case of exposure. Teams were restructured and subdivided to maximize physical distancing and minimize resident exposure to pathogens. Educational initiatives doubled, with virtual sessions targeting every resident year and incorporating intraoperative teaching. The divisional research day and oral exams proceeded uninterrupted, virtually. A small leadership team enabled fast and flexible restructuring of a system for patient care while prioritizing resident safety and maintaining a commitment to resident education in a pandemic., The coronavirus disease 2019 (COVID-19) pandemic presents an unprecedented challenge to health care. As of April 19, 2020, Ontario had approximately 10 500 confirmed cases (1) and adopted physical distancing [...]