Search

Purpose: Forceful coughing is assumed to be an uncommon etiology for lateral abdominal wall hernias. The literature regarding this topic is very limited and there is a lack of consensus in management, both operative and non-operative. We aim to report our center's experience in repair of lateral abdominal wall hernias secondary to vigorous coughing., Methods: All patients undergoing lateral abdominal wall hernia repairs secondary to coughing at our institution from August 2014 to December 2023 were identified in the Abdominal Core Health Quality Collaborative (ACHQC). Only patients with lateral abdominal wall hernias without prior lateral incisions, reporting a vigorous coughing event were included in the analysis. Recurrent repairs were also included. Patient and hernia characteristics, operative details, post-operative outcomes, and long-term patient reported outcomes were extracted from the ACHQC database and chart review., Results: Twelve patients with lateral abdominal wall hernias secondary to coughing underwent repair within the study period. The median hernia width was 18.5 cm. Transversus abdominus release was performed in all patients, 8 had heavyweight polypropylene mesh placed, and 9 received mesh fixation. Wound complications were noted in 2 patients, both resolved with superficial wound opening. At a mean follow up of 4.0 years, one patient reported a bulge, and no clinical or radiographic recurrences were identified., Conclusion: Lateral abdominal wall hernias after forceful coughing have not been well defined. Here we present our series based on our repairs. Unfortunately, our ability to comment on recurrences is limited by a lack of follow up., Competing Interests: Declarations. Conflict of interest: Dr. Maskal accepted a Resident Research Grant from the Abdominal Core Health Quality Collaborative. Dr. Miller received a research grant from the American Hernia Society and research funding for his institution from Integra. Dr. Petro serves as an Advanced Medical Solutions, Bard-Davol, and Surgimatix Consultant, and has received research grants from the American Hernia Society, the Central Surgical Association, and the Society of American Gastrointestinal and Endoscopic Surgeons. Dr. Prabhu is on the advisory board for Surgimatix and CMR Surgical. Dr. Rosen serves as the medical director of the ACHQC and receives salary for this position, received a grant to his institution for research from Telabio and has stock options with Ariste. Dr. Ellis, Dr. Bertke, Dr. Figueiredo, Dr. Fafaj, Dr. Woo, Dr. Messer, Dr. Remulla, Dr. Krpata, and Dr. Beffa have no disclosures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Importance: Paraesophageal hernias can cause severe limitations in quality of life and life-threatening complications. Even though minimally invasive paraesophageal hernia repair (MIS-PEHR) is safe and effective, anatomic recurrence rates remain notoriously high. Retrospective data suggest that suturing the stomach to the anterior abdominal wall after repair-an anterior gastropexy-may reduce recurrence, but this adjunct is currently not the standard of care., Objective: To determine whether anterior gastropexy reduces 1-year recurrence after MIS-PEHR., Design, Setting, and Participants: This registry-based randomized clinical trial was conducted by 10 surgeons at 3 academic hospitals within the Cleveland Clinic Enterprise. Between June 26, 2019, and July 24, 2023, 348 patients were assessed for eligibility, and 240 patients were enrolled and randomized. Statistical analysis was performed from January to March 2024., Intervention: Enrolled patients were randomized to and received either an anterior gastropexy (n = 119) or no anterior gastropexy (n = 121)., Main Outcome: The primary outcome was recurrence as determined by reherniation of the stomach greater than 2 cm above the diaphragm on routine imaging at 1 year or reoperation. Secondary outcomes included quality of life as measured by the Gastroesophageal Reflux Health-Related Quality of Life survey, additional foregut symptom questionnaire, and patient satisfaction at 30 days and 1 year., Results: A total of 240 patients were randomized to either anterior gastropexy (n = 119; 104 [97%] women; median [IQR] age, 70 [64-75] years) or no anterior gastropexy (n = 121; 97 [80%] women; median [IQR] age, 68 [62-73] years) at the end of their MIS-PEHR. At 1 year, 188 patients (78%) had completed follow-up. By intention-to-treat analysis, 1-year recurrence was significantly lower in patients who received an anterior gastropexy (15% vs 36%; risk difference, 0.21 [95% CI, 0.09-0.33]), which remained significant after risk-adjusted regression analysis (hazard ratio, 0.38 [95% CI, 0.23-0.60]). Of 13 reoperations (5.4%) for recurrence in the first year, 3 (2.5%) were in the anterior gastropexy group and 10 (8.2%) were in the no-gastropexy group (P = .052). Two patients (1.7%) had their anterior gastropexy sutures removed for pain. There were no significant differences in quality-of-life outcomes at 30 days and 1 year between treatment groups., Conclusions and Relevance: This randomized clinical trial found that the addition of an anterior gastropexy to MIS-PEHR is superior to no gastropexy in regard to reducing 1-year paraesophageal hernia recurrence. These results suggest that an anterior gastropexy should be routinely used in the context of minimally invasive paraesophageal hernia repair., Trial Registration: ClinicalTrials.gov Identifier: NCT04007952.

Introduction: Recurrent paraesophageal hernia (PEH) repair presents significant technical challenges, with limited data weighing the benefit to the operative risk. This study aims to describe our experience with recurrent PEH repair, including long-term surgical and patient reported outcomes (PROs)., Methods: We conducted a retrospective review of recurrent PEH repairs from June 2018-March 2023 using our institutional database. A blinded review of post-operative imaging was conducted to assess for recurrence. Quality of life (QOL) and decision regret were measured using the GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire and Decision Regret Scale (DRS) at maximum follow up., Results: Eighty-eight patients underwent recurrent PEH repair at our institution for PEH, classified as type II (13.6%), type III (72.7%) and type IV (13.6%). There was significant heterogeneity in operative techniques used: one-third of patients had mesh placed at the hiatus, 11.4% had a Collis gastroplasty, and one-third of patients underwent fundoplication. Intraoperative complications included gastric (5.7%), esophageal (2.3%), vascular (1.1%) and pulmonary (1.1%) injuries. Follow up was available for 73 patients with median follow up of 35.2 months. Of patients with radiographic follow up, 20 (35.7%) had a radiographic recurrence: 12 (21.4%) were 2-5 cm and 8 (14.3%) were > 5 cm. Patients reporting PROs (53 patients; 60.2%) reported low symptom severity (mean GERD-HRQL 13.1 ± 12) and low decision regret (mean DRS 13.3 ± 19.4) with 75.5% scoring in the lowest quartile (DRS < 25). Radiographic recurrence was associated with worse QOL (p < 0.05), but no significant difference in decision regret (p = 0.125)., Conclusion: We found significant heterogeneity amongst recurrent PEH repair techniques with continued high recurrence rate during follow up. Radiographic recurrence was correlated with worse QOL, yet patients reported low symptom severity and low decision regret, suggesting continued value in these challenging operations. Future studies should aim to identify more effective techniques to reduce recurrence rates in this patient population., Competing Interests: Declarations. Disclosures: Daphne Remulla, Kimberly P. Woo, Ryan C. Ellis, William C. Bennet, Aldo Fafaj, Salvador Navarrete, David M. Krpata, and Lucas R. Beffa have no conflicts of interest or financial ties to disclosures. Sara M. Maskal has received a research grant from the American Core Health Quality Collaborative. Benjamin T. Miller has received a research grant from the American Hernia Society. Clayton C. Petro serves as a consultant for Advanced Medical Solutions, Bardt-Davol, and Surgimatix, and has received research grants from the American Hernia Society, the Central Surgical Association, and the Society of American Gastrointestinal and Endoscopic Surgeons. Ajita S. Prabhu is on the advisory board for Surgimatrix and CMR Surgical and receives consulting fees from CMR Surgical and Verb Surgical. Michael J. Rosen serves as the medical director of the American Core Health Quality Collaborative, has received a grant to his institution for research from Telabio, and has stock options with Ariste. None of these disclosures are relevant to this study., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Numerous studies have identified diabetes mellites (DM) as a significant risk factor for postoperative wound morbidity, with suboptimal preoperative glycemic control (GC) posing an even greater risk. However, this data largely excludes ventral hernia patients. Our study examined the association between diabetes and preoperative GC and postoperative outcomes following open complex abdominal wall reconstruction (AWR)., Methods: We identified diabetic patients who had undergone open, elective, clean VHR with transversus abdominis release (TAR) and permanent synthetic mesh at the Cleveland Clinic Foundation between January 2014 and December 2023. Their 30-day outcomes were compared to non-diabetic patients undergoing the same procedure. Subsequently, diabetic patients were categorized based on GC. status: "Optimal GC" (HbA1c < 7%), "Sub-optimal GC" (HbA1c 7-8.4%), and "Poor GC" (HbA1c ≥ 8.5%) and their outcomes were compared., Results: 514 patients with DM who underwent clean elective TAR were identified, of which 431 met the inclusion criteria. GC was deemed optimal in 255 patients, sub-optimal in 128, and poor in 48 patients. Demographics were similar, except for anticoagulation treatment (p = 0.014). The entire study population exhibited significantly higher rates of wound morbidities and overall complications compared to non-diabetic patients. However, rates of surgical site infection (SSI), surgical site occurrence (SSO), SSO requiring procedural intervention (SSOPI), and reoperation did not differ significantly among the three cohorts of presurgical glycemic control (p = 0.82, p = 0.46, p = 0.51, p = 0.78), respectively. No occurrence of mesh removal was documented., Conclusion: In general, diabetes is a marker for increased wound morbidity and complications following complex abdominal wall reconstruction. However, we could not establish a hard cutoff to justify withholding surgery in symptomatic patients based on an arbitrary HbA1C level. We believe this data is important for shared decision-making when considering AWR for symptomatic ventral hernias in diabetic patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Numerous clinical practice guidelines and consensus statements have been published in hernia surgery, however, there is still a need for high-quality evidence to address remaining unanswered questions. The aim of this study was to conduct research priority setting through a modified Delphi process to identify a list of top research priorities in hernia surgery., Methods: A structured literature review of clinical practice guidelines was performed by the steering committee. Topics considered clinically significant, practical to study and lacking strong evidence were extracted and refined into a comprehensive list, then entered into a two-round Delphi survey for prioritization at the Abdominal Core Health Quality Collaborative (ACHQC) Quality Improvement Summit. In round 1, participants were instructed to select any topic that should be prioritized for future research. Topics were ranked according to the proportion of votes and the 25 highest-ranking topics were included in the second round. In round 2, participants were instructed to select only the top 10 topics for research prioritization., Results: Eleven clinical practice guidelines were reviewed. Eighty-seven topics were extracted by the steering committee and submitted for prioritization. After the first round, 25 of the highest-ranking topics were determined and included in the second round. A final list of 11 research questions was identified. The hernia types with the most research interest were inguinal and epigastric/umbilical hernias. Other topics of high interest were the management of diastasis recti, primary versus mesh repairs and expectant management versus surgical repair., Conclusion: Our study provides a research agenda generated through expert consensus that may be used in the prioritization of the design and funding of clinical trials in hernia surgery., (© 2024. The Author(s).)

Background: Traumatic abdominal wall hernias are rare and commonly involve the lateral abdominal wall due to shearing off the oblique and transversus abdominis muscles from the iliac crest. The vast majority of the current literature focuses on the index trauma admission, includes few patients, and provides little to no detail about the hernia repair itself. We aim to report our center's high-volume experience with a definitive repair of chronic traumatic lateral abdominal wall hernias., Methods: All patients who underwent lateral abdominal wall hernia repair performed at our institution from January 2015 through August 2023 were identified in the Abdominal Core Health Quality Collaborative. Only patients with blunt trauma etiology were included. Hernia characteristics, operative techniques, postoperative outcomes, and long-term patient-reported outcomes were extracted from the Abdominal Core Health Quality Collaborative database and supplemented with a manual chart review., Results: Forty-three patients with traumatic lateral abdominal wall hernias underwent repair within the study period. Elective repair occurred at a median of 3 years after a traumatic event. Nearly half of the patients had a recurrent hernia (41.9%) and most had a lumbar (L4) component (79.1%). The mean hernia width was 16.2 cm, and 30.2% had concomitant midline defects. Transversus abdominis release was performed in 88.4% of patients; 74.5% had heavy-weight polypropylene mesh placed and 76.7% had mesh fixation. Superficial surgical site infection occurred in 11.6% of patients, and 7% had a surgical site occurrence. At a mean follow-up of 1.9 years, 3 patients (7%) developed a hernia recurrence, which was noted on physical examination or imaging. One patient was reoperated on for recurrence, and 1 patient underwent partial mesh removal because of a chronic mesh infection., Conclusion: In the largest series of definitive repairs of complex lateral abdominal wall post-traumatic hernias to date, elective open complex abdominal wall reconstruction is safe and associated with low morbidity and hernia recurrence rates., Competing Interests: Conflict of Interest/Disclosure Clayton C. Petro has research grants from Central Surgical Association, American Hernia Society, and SAGES and acts as a consultant for BD and Surgimatix. Michael J. Rosen is the medical director of ACHQC and has stock options with Ariste. Ajita S. Prabhu accepts speaking fees and research support paid to institution from Intuitive Surgical, receives consulting fees, and is on the advisory board for CMR Surgical and Surgimatix. Lucas R. A. Beffa accepts honoraria from Intuitive Surgical. Sara M. Maskal accepted a resident research grant from ACHQC. The other authors have no financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Although hernia repair constitutes a significant portion of surgical training, education around more complex hernia concepts such as abdominal wall reconstruction (AWR) or paraesophageal hernia repair may be lacking. We developed and implemented a pre-rotation quiz for residents on an AWR and minimally invasive surgery service. We also investigated the staff and resident perception of resident knowledge and experience of the rotation before and after quiz implementation., Methods: The multiple-choice quiz questions were written by clinical and research fellows, validated by four staff, two fellows, and two senior residents and implemented in June 2023. Questions assessed knowledge of anatomy, operative steps, mesh materials, clinical trials, and postoperative management specific to ventral, inguinal, and paraesophageal hernia repairs. Residents were notified of the summative quiz three weeks prior and provided with reference materials specific to quiz questions. Anonymous Likert-type surveys were distributed to staff and residents between 3/2023 and 3/2024. Responses were assessed based on the overall score as well as individual domains and then compared based on whether they were completed before or after implementation of the quiz., Results: 17 seniors and 29 juniors rotated on service and all completed the pre-rotation quiz between 7/1/2023-3/4/2024. The mean first attempt score was 72%(± 12.4%) for junior residents and 88.4%(± 9.6%) for senior residents. Staff reported overall resident knowledge improved after quiz implementation (maximum 90, mean(SD): 46.25(± 8.58) vs. 75.5(± 11.24),p = 0.05). Sixteen(45.7%) residents responded to the survey before quiz implementation and 23(50%) after. Residents only reported improved knowledge regarding current literature (maximum 5, mean(SD):3.2 ± 0.98 vs. 3.8 ± 0.78,p = 0.04)., Conclusion: Implementing a pre-rotation quiz effectively improves staff perception of resident knowledge and preparation., Competing Interests: Declarations Competing interests Dr. Prabhu is on the advisory board for Surgimatix and CMR Surgical. Dr. Petro serves as an Advanced Medical Solutions, Bard-Davol, and Surgimatix Consultant, and has received research grants from the American Hernia Society, the Central Surgical Association, and the Society of American Gastrointestinal and Endoscopic Surgeons. Dr. Rosen serves as the medical director of the ACHQC and receives salary for this position, received a grant to his institution for research from Telabio and has stock options with Ariste. Dr. Miller received a research grant from the American Hernia Society and research funding for his institution from Integra. Dr. Maskal accepted a Resident Research Grant from the Abdominal Core Health Quality Collaborative. Dr. Beffa, Dr. Brooks, Dr. Ellis, Dr. Melland-Smith, and Dr. Messer have no disclosures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: When faced with contaminated ventral hernia repairs, surgeons must decide to repair the defect in a single-stage or delay the definitive repair until a clean scenario has been achieved. We sought to compare wound complications, long-term hernia recurrence and quality of life for patients who underwent delayed versus single-staged abdominal wall reconstruction (AWR) in the setting of clean-contaminated and contaminated wounds., Methods: The Abdominal Core Health Quality Collaborative was used to identify adult patients at our institution who underwent open AWR with retromuscular synthetic mesh placement between January 2014 and August 2023. The delayed group included patients who underwent clean-contaminated or contaminated abdominal operation in the setting of a ventral hernia without placement of permanent synthetic mesh, then underwent AWR with permanent synthetic mesh placement in a separate operation. The single-staged group had clean-contaminated or contaminated wounds concomitant with AWR. Outcomes of the AWR were compared., Results: 63 patients underwent a delayed AWR and 375 patients underwent a single-staged AWR with a median(IQR) follow-up of 3(2,5)years. Most common concomitant procedures involved small intestine(30%) or hepatobiliary(30%). Most common index operations in delayed AWR were ileostomy(52.4%) and colostomy(14.2%) reversals. Median(IQR) time between initial operation and definitive AWR was 1.0 (0.7, 1.9)years. Median(IQR) hernia width was 11.35(8.4, 15.0)cm at initial operation and 16.0(15.0,20.0)cm at AWR for the delayed group(p < 0.001). Three patients (19%) in the delayed group and 14(12%) in the single-staged underwent wound debridement within 30-days(p = 0.46); a single patient in each required partial mesh excision within 30-days(p = 0.098). Wound morbidity, reoperation and hernia recurrence were similar (p > 0.05)., Conclusion: In patients with a ventral hernia and separate indication for abdominal operation with a clean-contaminated or contaminated wound, either delayed or single-stage approaches to AWR may be viable., Competing Interests: Declarations Competing interests Dr. Prabhu is on the advisory board for Surgimatix and CMR Surgical. Dr. Petro serves as an Advanced Medical Solutions, Bard-Davol, and Surgimatix Consultant, and has received research grants from the American Hernia Society, the Central Surgical Association, and the Society of American Gastrointestinal and Endoscopic Surgeons. Dr. Rosen serves as the medical director of the ACHQC and receives salary for this position, received a grant to his institution for research from Telabio and has stock options with Ariste. Dr. Miller received a research grant from the American Hernia Society and research funding for his institution from Integra. Dr. Maskal accepted a Resident Research Grant from the Abdominal Core Health Quality Collaborative and honoraria from Momentis Surgical. Dr. Ellis and Dr. Woo accepted honoraria from Momentis Surgical. Mr. Mali, Dr. Beffa, Dr. Al Marzooqi, Dr. Huang and Dr. Remulla have no disclosures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Although intraoperative music is purported to mitigate postoperative pain after some procedures, its application has never been explored in abdominal wall reconstruction (AWR). We sought to determine whether intraoperative music would decrease early postoperative pain following AWR., Methods: We conducted a placebo-controlled, patient-, surgeon-, and assessor-blinded, randomized controlled trial at a single center between June 2022 and July 2023 including 321 adult patients undergoing open AWR with retromuscular mesh. Patients received noise-canceling headphones and were randomized 1:1 to patient-selected music or silence after induction, stratified by preoperative chronic opioid use. All patients received multimodal pain control. The primary outcome was pain (NRS-11) at 24 ± 3 h. The primary outcome was analyzed by linear regression with pre-specified covariates (chronic opioid use, hernia width, operative time, myofascial release, anxiety disorder diagnosis, and preoperative STAI-6 score)., Results: 178 patients were randomized to music, 164 of which were analyzed. 177 were randomized to silence, 157 of which were analyzed. At 24 ± 3 h postoperatively, there was no difference in the primary outcome of NRS-11 scores (5.18 ± 2.62 vs 5.27 ± 2.46, p = 0.75). After adjusting for prespecified covariates, the difference of NRS-11 scores at 24 ± 3 h between the music and silence groups remained insignificant (p = 0.83). There was no difference in NRS-11 or STAI-6 scores at 48 ± 3 and 72 ± 3 h, intraoperative sedation, or postoperative narcotic usage., Conclusion: For patients undergoing AWR, there was no benefit of intraoperative music over routine multimodal pain control for early postoperative pain reduction., Trial Registration: ClinicalTrials.gov: NCT05374096., (© 2024. The Author(s).)

Purpose: The Ventral Hernia Working Group (VHWG) proposed a ventral hernia grading guideline, primarily supported by expert opinion, recommending biologic mesh placement in high-risk patients. We investigated the relationship between this industry-sponsored guideline and discourse around ventral hernia repair (VHR)., Methods: Medline platform from Web of Science's database identified publications "pre-VHWG"(1999-01-01 to 2009-12-31), and "post-VHWG"(2010-01-01 to 2020-12-31) describing VHR and complications or recurrence of VHR with the following comorbidities: COPD, smoking, diabetes, immunosuppression, or obesity. Poisson regression analyzed keyword frequency over time using logarithmically transformed data., Results: Of 1291 VHR publications identified pre-VHWG and 3041 publications identified post-VHWG, 172 (13.3%) and 642 (21.1%) publications respectively included prespecified keywords. The keyword groups "biologic"(IRR 3.39,95%CI1.34-11.4,p = 0.022) and "comorbid"(IRR 1.95, 95%CI1.09-3.74,p = 0.033) significantly increased with frequency after publication of the VHWG., Conclusion: The VHWG publication likely contributed to a focus on comorbidities and biologic mesh in the ensuing literature within the field of VHR., (© 2024. The Author(s).)

Importance: Durable parastomal hernia repair remains elusive. There is limited evidence comparing the durability of the open retromuscular Sugarbaker and keyhole mesh configurations., Objective: To determine if the open retromuscular Sugarbaker mesh placement technique would lower parastomal hernia recurrence rates., Design, Setting, and Participants: In this single-center, randomized clinical trial, 150 patients with a permanent stoma and associated parastomal hernia who were candidates for open retromuscular parastomal hernia repair were enrolled and randomized from April 2019 to April 2022 and followed up for 2 years., Interventions: Following intraoperative assessment to determine the feasibility of either technique, enrolled patients were randomized to receive either retromuscular Sugarbaker or keyhole synthetic mesh placement., Main Outcomes and Measures: The primary outcome was parastomal hernia recurrence at 2 years. Secondary outcomes included mesh-related complications, wound complications, reoperations, as well as patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at 1 year and 2 years., Results: A total of 150 patients were randomized, and with 91% follow-up at 2 years, there were 13 (17%) parastomal hernia recurrences in the retromuscular Sugarbaker arm and 18 (24%) in the keyhole arm (adjusted risk difference, -0.029; 95% CI, -0.17 to 0.153, and adjusted risk ratio, 0.87; 95% CI, 0.42 to 1.69). There were no statistically significant differences between the Sugarbaker and keyhole groups regarding reoperations for recurrence (2 vs 7, respectively), nonhernia intra-abdominal pathology (4 vs 10, respectively), stoma necrosis (1 vs 0, respectively), mesh-related complications (4 vs 1, respectively), patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at any time point., Conclusions and Relevance: In the setting of open parastomal hernia repair, a retromuscular Sugarbaker mesh placement technique was not superior to a keyhole configuration 2 years after repair. Further innovation is necessary to improve parastomal hernia repair outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT03972553.

Introduction: Abdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. Despite the popularity of the TAR procedure, current literature regarding post-AWR surgeries is limited. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind., Methods: Adult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence., Results: A total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% of the patients required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17-30 months, resulting in a 36.1% recurrent hernia diagnosis rate., Conclusions: Abdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: As hospitals strive to reduce their environmental footprint, there is an ongoing debate over the environmental implications of reusable versus disposable linens in operating rooms (ORs). This research aimed to compare the environmental impact of reusable versus single-use OR bed covers and lift sheets using life cycle assessment (LCA) methodology., Methods: LCA is an established tool with rigorous methodology that uses science-based processes to measure environmental impact. This study compared the impacts of three independent system scenarios at a single large academic hospital: reusable bed covers with 50 laundry cycles and subsequent landfill disposal (System 1), single-use bed covers with waste landfill disposal (System 2), and single-use bed covers with waste disposal using incineration (System 3)., Results: The total carbon footprint of System 1 for 50 uses was 19.83 ​kg carbon dioxide equivalents (CO 2 -eq). System 2 generated 64.99 ​kg CO 2 -eq. For System 3, the total carbon footprint was 108.98 ​kg CO 2 -eq. The raw material extraction for all the material to produce an equivalent 50 single-use OR bed cover kits was tenfold more carbon-intensive than the reusable bed cover. Laundering one reusable OR bed cover 50 times was more carbon intensive (12.12 ​kg CO2-eq) than landfill disposal of 50 single-use OR bed covers (2.52 ​kg CO2-eq)., Discussion: Our analysis demonstrates that one reusable fabric-based OR bed cover laundered 50 times, despite the carbon and water-intensive laundering process, exhibits a markedly lower carbon footprint than its single-use counterparts. The net difference is 45.16 ​kg CO2-eq, equivalent to driving 115 miles in an average gasoline-powered passenger vehicle. This stark contrast underscores the efficacy of adopting reusable solutions to mitigate environmental impact within healthcare facilities., Competing Interests: Declaration of competing interest The authors have no financial disclosures nor conflicts of interest to report., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Recurrent ventral hernia repair can be challenging due to scarred tissue planes and the increasing complexity of disease related to multiple recurrences. Given the challenges of acquiring complete and accurate prior operative reports, surgeons often rely on computed tomography (CT) scans to obtain information and plan for re-operation. Still, the contribution of CT scans and the ability of surgeons to interpret them is controversial. Previously, we examined the ability of surgeons to determine prior operative techniques based on CT scans. Here, we assessed the accuracy of expert abdominal wall reconstruction (AWR) surgeons in identifying the type of prior mesh using CT imaging., Methods: A total of 22 highly experienced AWR surgeons were asked to evaluate 21 CT scans of patients who had undergone open ventral hernia repair with bilateral transversus abdominis release utilizing mesh. The surgeons were required to identify the mesh type from a multiple-choice selection. Additionally, negative controls (patients without a history of prior laparotomy) and positive controls (patients with laparotomy but no ventral hernia repair) were incorporated. The accuracy of the surgeons and interrater reliability was calculated., Results: The accuracy rate of the surgeons in correctly identifying the mesh type was 46%, with heavy-weight synthetic mesh (HWSM) being identified only 35.4% of the time, Strattice mesh and medium-weight synthetic mesh (MWSM) were identified at 46.3%, and 51.8%, respectively. The interrater reliability analysis found a moderate level of agreement 0.428 (95% CI 0.356-0.503), and the repeatability measure was poor-0.053 (95% CI 0-0.119); this indicates that surgeons cannot reliably replicate the identification process., Conclusions: Surgeons' ability to accurately identify the type of previous mesh using CT scans is poor. This study underscores the importance of documenting the type of mesh used in the operative report and the need for standardized operative notes to improve the accuracy and consistency of documentation., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objective: Since the inception of Ken Lee Memorial Fellowship (KLMF) in 2013, our institution has achieved 10 years of trainee led sustainability projects. The ability of health care organizations to drive sustainability depends on organizational and human capacity. This qualitative study presents the first decade of sustainability fellows' projects, the challenges associated with implementing them, and the environmental and cost impact of these initiatives., Design, Setting, Participants: All residents in the General Surgery residency program at the Cleveland Clinic, a quaternary hospital, regardless of postgraduate year (PGY) level, are invited to apply for the KLMF program with a short project proposal. One fellow is selected per year. Each project since the program's inception was reviewed qualitatively, relying on data derived from observation, interview of prior fellows, and supervising staff, and analysis of documentation from the annual fellow presentation and abstract, Grand Rounds recording, and fellowship leadership., Results: A targeted approach by each sustainability fellow is encouraged, with the following action cycle for change implementation throughout the 1-year fellowship: identification and discovery of an issue, collaborative planning of an intervention, implementation of the intervention, and evaluation. Projects range from water and waste reduction to education of surgical staff, with positive implications for environmental stewardship in our hospital. However, multiple barriers to completing, scaling, and maintaining sustainability initiatives remain, as demonstrated by challenges faced by our Ken Lee Fellows., Conclusions: Our goal is that this intensive educational experience within the framework of a graduate medical education curriculum will ensure future generations of surgeons who are thoughtful leaders in environmental stewardship., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Abdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction., Methods: All patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion., Results: In 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75-43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34-8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention., Conclusion: Patients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk., (Published by Elsevier Inc.)

Background: Mediumweight (40-60 g/m 2 ) polypropylene (MWPP) mesh has been shown to be safe and effective in CDC class II-III retromuscular ventral hernia repairs (RMVHR). However, MWPP has the potential to fracture, and it is possible that heavyweight (> 75 g/m 2 ) polypropylene mesh has similar outcomes in this context. However, there is limited data on HWPP mesh performance in clean-contaminated and contaminated scenarios. We aimed to compare HWPP to MWPP mesh in CDC class II-III wounds during open RMVHR., Methods: The Abdominal Core Health Quality Collaborative database was retrospectively queried for a cohort of patients who underwent open RMVHR with MWPP or HWPP mesh placed in CDC class II/III wounds from 2012 to 2023. Mesh types were compared using a 3:1 propensity score-matched analysis. Covariates for matching included CDC classification, BMI, diabetes, smoking within 1 year, hernia, and mesh width. Primary outcome of interest included wound complications. Secondary outcomes included reoperations and readmissions at 30 days., Results: A total of 1496 patients received MWPP or HWPP (1378 vs. 118, respectively) in contaminated RMVHR. After propensity score matching, 351 patients remained in the mediumweight and 117 in the heavyweight mesh group. There were no significant differences in surgical site infection (SSI) rates (13.4% vs. 14.5%, p = 0.877), including deep SSIs (0.3% vs. 0%, p = 1), surgical site occurrence rates (17.9% vs. 22.2%, p = 0.377), surgical site occurrence requiring procedural intervention (16% vs. 17.9%, p = 0.719), mesh removal (0.3% vs. 0%, p = 1), reoperations (4.6% vs. 2.6%, p = 0.428), or readmissions (12.3% vs. 9.4%, p = 0.504) at 30 days., Conclusion: HWPP mesh was not associated with increased wound morbidity, mesh excisions, reoperations, or readmissions in the early postoperative period compared with MWPP mesh in open RMVHR for CDC II/III cases. Longer follow-up will be necessary to determine if HWPP mesh may be a suitable alternative to MWPP mesh in contaminated scenarios., (© 2024. The Author(s).)

Introduction: In the Transversus Abdominis Release (TAR) procedure, ideally, the posterior sheath is completely reapproximated to establish an interface isolating the polypropylene mesh from visceral contents. When primary closure of the posterior sheath is unachievable, Vicryl mesh is commonly used to supplement the posterior sheath closure and an uncoated polypropylene mesh is placed superficial to the Vicryl mesh. The long-term implications of utilizing Vicryl mesh as an antiadhesive barrier are poorly understood. In this study, we aimed to assess our outcomes when utilizing Vicryl mesh to supplement the posterior sheath defects when placed underneath polypropylene mesh in patients undergoing posterior component separation., Methods: Adult patients who underwent VHR with concurrent TAR procedure with a permanent synthetic mesh and posterior sheath supplementation with Vicryl mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and December 2022 were queried retrospectively from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term mesh-related complications, and pragmatic hernia recurrence., Results: 53 patients who underwent TAR procedure with posterior sheath supplementation using Vicryl mesh and had a minimum 12-month follow-up were identified. Of the 53 patients, 94.3% presented with recurrent hernias, 73.6% had a midline hernia, 7.5% had a flank hernia, and 18.9% had concurrent parastomal hernia. The mean hernia width was 24.9 cm (± 8.8 cm). No Vicryl mesh-related operative complications were identified in our study, with no instances of mesh erosion, fistulas, or interventions for small bowel obstruction. Skin necrosis requiring reoperations was observed in three patients (5.7%), leading to permanent mesh excision in two cases (3.8%) without intraabdominal visceral involvement. Throughout the 12-month follow-up, 23 incidences (43.4%) of surgical site occurrences (SSOs) and surgical site occurrences requiring procedural intervention (SSOPI) were documented., Conclusions: Our findings suggest that posterior sheath supplementation with Vicryl mesh is a feasible approach to achieve posterior sheath closure in challenging abdominal wall reconstruction cases. Given the absence of notable mesh-related complications and a similar hernia recurrence rate to cases without posterior sheath supplementation, Vicryl mesh can be used to safely achieve posterior sheath closure in complex reconstructions with insufficient native tissue., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Ventral hernias result in fibrosis of the lateral abdominal wall muscles, increasing tension on fascial closure. Little is known about the effect of abdominal wall tension on outcomes after abdominal wall reconstruction. We aimed to identify an association between abdominal wall tension and early postoperative outcomes in patients who underwent posterior component separation (PCS) with transversus abdominis release (TAR)., Study Design: Using a proprietary, sterilizable tensiometer, the tension needed to bring the anterior fascial elements to the midline of the abdominal wall during PCS with TAR was recorded. Tensiometer measurements, in pounds (lb), were calibrated by accounting for the acceleration of Earth's gravity. Baseline fascial tension, change in fascial tension, and fascial tension at closure were evaluated with respect to 30-day outcomes, including wound morbidity, hospital readmission, reoperation, ileus, bleeding, and pulmonary complications., Results: A total of 100 patients underwent bilateral abdominal wall tensiometry, for a total of 200 measurements (left and right side for each patient). Mean baseline anterior fascial tension was 6.78 lb (SD 4.55) on each side. At abdominal closure, the mean anterior fascial tension was 3.12 (SD 3.21) lb on each side. Baseline fascial tension and fascial tension after PCS with TAR at abdominal closure were not associated with surgical site infection, surgical site occurrence, readmission, ileus, and bleeding requiring transfusion. The event rates for all other complications were too infrequent for statistical analysis., Conclusions: Baseline and residual fascial tension of the anterior abdominal wall do not correlate with early postoperative morbidity in patients undergoing PCS with TAR. Further work is needed to determine if abdominal wall tension in this context is associated with long-term outcomes, such as hernia recurrence., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Individuals diagnosed with connective tissue disorders (CTD) are known to be predisposed to incisional hernia formation. However, there is a scarcity of data on outcomes for these patients undergoing hernia repair. We sought to describe our outcomes in performing abdominal wall reconstructions in these complex patients., Methods: Adult patients with CTD undergoing open, elective, posterior component separation with permanent synthetic mesh at our institution from January 2018 to October 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term hernia recurrence, and patient-reported quality of life., Results: Twelve patients were identified. Connective tissue disorders included Marfan's n = 7 (58.3%), Loeys-Dietz syndrome n = 2 (16.7%), Systemic Lupus Erythematosus n = 2 (16.7%), and Scleroderma n = 1 (8.3%). Prior incisions included three midline laparotomies and nine thoracoabdominal, mean hernia width measured 14 cm, and 9 were recurrent hernias. Surgical site occurrences (SSOs) were observed in 25% of cases, and 16.7% necessitated procedural intervention. All twelve patients were available for long-term follow-up, with a mean of 34 (12-62) months. There were no instances of reoperation or mesh excision related to the TAR procedure. One patient developed a recurrence after having his mesh violated for repair of a new visceral aneurysm. Mean HerQLes scores at 1 year were 70 and 89 at ≥ 2 years; Mean scaled PROMIS scores were 30.7 at 1 year and 36.3 at ≥ 2 years., Conclusion: Ventral hernia repair with TAR is feasible in patients with connective tissue disorder and can be a suitable alternative in patients with large complex hernias., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Despite increasing use of cannabis, literature on perioperative effects is lagging. We compared active cannabis-smokers versus non-smokers and postoperative wound morbidity and reoperations following open abdominal wall reconstruction (AWR)., Methods: Patients who underwent open, clean, AWR with transversus abdominis release and retromuscular synthetic mesh placement at our institution between January 2014 and May 2022 were identified using the Abdominal Core Health Quality Collaborative database. Active cannabis-smokers were 1:3 propensity matched to non-smokers based on demographics and comorbidities. Wound complications, 30 day morbidity, pain (PROMIS 3a-Pain Intensity), and hernia-specific quality of life (HerQles) were compared., Results: Seventy-two cannabis-smokers were matched to 216 non-smokers. SSO (18% vs 17% p = 0.86), SSI (11.1% vs 9.3%, p = 0.65), SSOPI (12% vs 12%, p = 0.92), and all postoperative complications (46% vs 43%, p = 0.63) were similar between cannabis-smokers and non-smokers. Reoperations were more common in the cannabis-smoker group (8.3% vs 2.8%, p = 0.041), driven by major wound complications (6.9% vs 3.2%, p = 0.004). No mesh excisions occurred. HerQles scores were similar at baseline (22 [11, 41] vs 35 [14, 55], p = 0.06), and were worse for cannabis-smokers compared to non-smokers at 30 days (30 [12, 50] vs 38 [20, 67], p = 0.032), but not significantly different at 1 year postoperatively (72 [53, 90] vs 78 [57, 92], p = 0.39). Pain scores were worse for cannabis-smokers compared to non-smokers at 30 days postoperatively (52 [46, 58] vs 49 [44, 54], p = 0.01), but there were no differences at 6 months or 1 year postoperatively (p > 0.05 for all)., Conclusion: Cannabis smokers will likely experience similar complication rates after clean, open AWR, but should be counseled that despite similar wound complication rates, the severity of their wound complications may be greater than non-smokers., (© 2024. The Author(s).)

Purpose: Parastomal hernias are a common and challenging problem with high rates of wound complications and hernia recurrence after repair. We present our approach to optimizing parastomal hernia repair through preoperative preparation, surgical approach, and postoperative management., Methods: Patients are carefully evaluated and optimized prior to surgery. Our typical surgical approach involves a generous midline laparotomy and retrorectus dissection followed by a posterior component separation with transversus abdominis release. We typically utilize a Sugarbaker technique for retromuscular mesh placement but also use the retromuscular keyhole or cruciate technique if there is insufficient bowel length., Results: Previously published results from our institution include wound complication rates of up to 16% after open retromuscular parastomal hernia repair. Stoma-specific complications, such as mesh erosion in the bowel, may be attributed to the mesh placement techniques. Hernia recurrence rates range from 11 to 30% up to 2 years postoperatively., Conclusion: We prefer an open retromuscular approach with a Sugarbaker mesh configuration to treat complex parastomal hernias. However, wound morbidity and repair failure rates remain high, and additional research is needed to optimize surgical outcomes., (© 2024. The Author(s).)

Introduction: Fixation of mesh during minimally invasive inguinal hernia repair is thought to contribute to chronic post-herniorrhaphy groin pain (CGP). In contrast to permanent tacks, absorbable tacks are hypothesized to minimize the likelihood of CGP. This study aimed to compare the rates of CGP after laparoscopic inguinal hernia repair between absorbable versus permanent fixation at maximum follow-up., Methods: This is a post hoc analysis of a randomized controlled trial in patients undergoing laparoscopic inguinal hernia repair (NCT03835351). All patients were contacted at maximum follow-up after surgery to administer EuraHS quality of life (QoL) surveys. The pain and restriction of activity subdomains of the survey were utilized. The primary outcome was rate of CGP, as defined by a EuraHS QoL pain domain score ≥ 4 measured at ≥ 1 year postoperatively. The secondary outcomes were pain and restriction of activity domain scores and hernia recurrence at maximum follow-up., Results: A total of 338 patients were contacted at a mean follow-up of 28 ± 11 months. 181 patients received permanent tacks and 157 patients received absorbable tacks during their repair. At maximum follow-up, the rates of CGP (27 [15%] vs 28 [18%], P = 0.47), average pain scores (1.78 ± 4.38 vs 2.32 ± 5.40, P = 0.22), restriction of activity scores (1.39 ± 4.32 vs 2.48 ± 7.45, P = 0.18), and the number of patients who reported an inguinal bulge (18 [9.9%] vs 15 [9.5%], P = 0.9) were similar between patients with permanent versus absorbable tacks. On multivariable analysis, there was no significant difference in the odds of CGP between the two groups (OR 1.23, 95% CI [0.60, 2.50])., Conclusion: Mesh fixation with permanent tacks does not appear to increase the risk of CGP after laparoscopic inguinal hernia repair when compared to fixation with absorbable tacks. Prospective trials are needed to further evaluate this relationship., (© 2024. The Author(s).)

Introduction: Intraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs., Methods and Procedures: Adult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively., Results: A total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8-5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up., Conclusion: Intraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons., (© 2024. The Author(s).)

Purpose: Heavyweight polypropylene (HWPP) mesh is thought to increase inflammatory response and delay tissue integration compared to mediumweight (MWPP). Reactive fluid volume (i.e., drain output) may be a reasonable surrogate for integration. We hypothesized that daily drain output is higher with HWPP compared to MWPP in open retromuscular ventral hernia repair (VHR)., Methods: This is a post-hoc analysis of a multicenter, randomized clinical trial conducted March 2017-April 2019 comparing MWPP and HWPP for VHR. Retromuscular drain output in milliliters was measured at 24-h intervals up to postoperative day seven. Univariate analyses compared differences in daily drain output and time to drain removal. Multivariable analyses compared total drain output and wound morbidity within 30 days and hernia recurrence at 1 year., Results: 288 patients were included; 140 (48.6%) HWPP and 148 (51.4%) MWPP. Daily drain output for days 1-3 was higher for HWPP vs. MWPP (total volume: 837.8 mL vs. 656.5 mL) (p < 0.001), but similar on days 4-7 (p > 0.05). Median drain removal time was 5 days for both groups. Total drain output was not predictive of 30-day wound morbidity (p > 0.05) or hernia recurrence at 1 year (OR 1, p = 0.29)., Conclusion: While HWPP mesh initially had higher drain outputs, it rapidly returned to levels similar to MWPP by postoperative day three and there was no difference in clinical outcomes. We believe that drains placed around HWPP mesh can be managed similarly to MWPP mesh., (© 2024. The Author(s).)

Introduction: Guidelines recommend MIS repairs for females with inguinal hernias, despite limited evidence. We investigated rates of femoral hernias intraoperatively noted during MIS and Lichtenstein repairs in females., Methods: ACHQC was queried for adult females undergoing inguinal hernia repair between January 2014-November 2022. Outcomes included identified femoral hernia and size, hernia recurrence, quality of life, and sex-based recurrence., Results: 1357 and 316 females underwent MIS and Lichtenstein inguinal repair respectively. Femoral hernias were identified more frequently in MIS than open repairs (27%vs12%; (p ​< ​0.001). Most femoral hernias in MIS (61%) and Lichtenstein repairs (62%) were <1.5 ​cm(p ​< ​0.001). Identification rates of femoral hernias >3 ​cm were 1% overall(p ​= ​0.09). Surgeon and patient-reported recurrences were similar between approaches at 1-5-years for females(p ​> ​0.05 for all) and similar between sexes(p ​> ​0.05)., Conclusion: Most incidental femoral hernias are small and both repair approaches demonstrated similar outcomes. The recommendation for MIS inguinal hernia repairs in females is potentially overstated., Competing Interests: Declaration of competing interest All authors have read and approved the manuscript. This manuscript is not under consideration elsewhere. This research was not funded., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Mesh has been the acceptable standard for incisional hernia repair regardless of hernia size. It is not clear whether there is a size of incisional hernias in whom repair would be best performed without mesh. This study aims to compare outcomes of mesh versus suture repairs for incisional hernias <2 cm in size., Methods: Incisional hernia repairs from 2012 to 2021 for hernias ≤2 cm in width were queried from the Abdominal Core Health Quality Collaborative. Those with 1-year follow up were considered. Hernia recurrence was defined using composite hernia recurrence, which combines both clinical and patient reported outcomes. Propensity score matching was performed between mesh and non-mesh using body mass index, smoking, diabetes, and drains as covariates., Results: A total of 352 patients met inclusion criteria. After propensity score matching, there were 132 repairs with mesh and 71 without. There was no difference in recurrence rates at 1 year between mesh and non-mesh repairs (15% vs 24%, P = .12). Mesh was associated with a higher rate of 30-day postoperative complications (11% vs 1%, P = .017). There were no differences in 1-year quality of life scores., Conclusion: The repair of incisional hernias ≤2 cm without mesh results in similar recurrence rates, similar quality of life scores, and lower postoperative early complications compared with repairs with mesh. Our findings suggest that there may be select patients with small incisional hernias that could reasonably undergo incisional hernia repair without mesh. Longer-term follow-up is needed to confirm ideal candidates and durability of these repairs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Morbid obesity, with a body mass index 35 kg/m 2 , is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes., Methods: Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh-to-hernia size ratio., Results: A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14-1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13-1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m 2 group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02-1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year., Conclusion: Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m 2 should not be used to deny symptomatic patients abdominal wall reconstruction., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days., Methods: This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications., Results: A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days., Conclusion: Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Many studies identify active smoking as a significant risk factor for postoperative wound and mesh complications in patients undergoing abdominal wall reconstruction surgery. However, our group conducted an analysis using data from the ACHQC database, which revealed similar rates of surgical site infection (SSI) and surgical site occurrence requiring procedural intervention (SSOPI) between active smokers and non-smokers As a result, the Cl eveland Clinic Center for Abdominal Core Health instituted a policy change where active smokers were no longer subject to surgical delay. Our study aims to evaluate the impact of active smoking on the outcomes of these patients., Methods: We identified active smoking patients who had undergone open, elective, clean ventral hernia repair (VHR) with transversus abdominis release (TAR) and permanent synthetic mesh at Cleveland Clinic Foundation. Propensity matching was performed to create a 1:3 ratio of "current-smokers" and "never-smokers" and compared wound complications and all 30-day morbidity between the two groups., Results: 106 current-smokers and 304 never-smokers were matched. Demographics were similar between the two groups after matching, with the exception of chronic obstructive pulmonary disease (COPD) (22.1% vs. 13.4%, p ​< ​.001) and body mass index (BMI) (31.1 vs. 32.6, p ​= ​.02). Rates of SSI (12.2% vs. 6.9%, p ​= ​.13), SSO (21.7% vs. 13.2%, p ​= ​.052), SSOPI (11.3% vs. 6.3%, p ​= ​.13), and reoperation (1.9% vs. 3.9%, p ​= ​.53) were not significantly different between active smokers and never-smokers correspondingly. One case (0.3%) of partial mesh excision was observed in the never-smokers group (p ​= ​1). The current-smokers group exhibited a significantly higher incidence of pneumonia compared to the never-smokers group (5.7% vs. 0.7%, p ​= ​.005)., Conclusion: Our study revealed that operating on active smokers did result in a slight increase in wound morbidity, although it did not reach statistical significance. Additionally, pulmonary complications were higher in the smoking group. Notably, we did not see any mesh infections in the smoking group during early follow up. We believe that this data is important for shared decision making on patients that are actively smoking contemplating elective hernia repair., Competing Interests: Declaration of competing interest Conflict of interest M.J.R. receives salary support for his position in the leadership of the Abdominal Core Health Quality Collaborative (ACHQC), which is the data source for the present submission, and he receives board member support and stock options from Ariste Medical. A.S.P. has received funding paid to her institution from Intuitive Surgical Inc., and personal fees from Medtronic, Intuitive Surgical, CMR Surgical, and Verb Surgical. D.M.K. has no declarations. L.R.B has received an honorarium from Intuitive., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Posterior components separation (PCS) is a commonly used myofascial release technique in ventral hernia repairs. The contribution of each release with anterior and posterior fascial advancement has not yet been characterized in patients with ventral hernias., Objective: To quantitatively assess the changes in tension on the anterior and posterior fascial elements of the abdominal wall during PCS to inform surgeons regarding the technical contribution of each step with those changes, which may help to guide intraoperative decision-making., Design, Setting, and Participants: This case series enrolled patients from December 2, 2021, to August 2, 2022, and was conducted at the Cleveland Clinic Center for Abdominal Core Health. The participants included adult patients with European Hernia Society classification M1 to M5 ventral hernias undergoing abdominal wall reconstruction with PCS., Intervention: A proprietary, sterilizable tensiometer measured the force needed to bring the fascial edge of the abdominal wall to the midline after each step of a PCS (retrorectus dissection, division of the posterior lamella of the internal oblique aponeurosis, and transversus abdominis muscle release [TAR])., Main Outcome: The primary study outcome was the percentage change in tension on the anterior and posterior fascia associated with each step of PCS with TAR., Results: The study included 100 patients (median [IQR] age, 60 [54-68] years; 52 [52%] male). The median (IQR) hernia width was 13.0 (10.0-15.2) cm. After complete PCS, the mean (SD) percentage changes in tension on the anterior and posterior fascia were -53.27% (0.53%) and -98.47% (0.08%), respectively. Of the total change in anterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -82.56% (0.68%), incision of the posterior lamella of the internal oblique with a change of -17.67% (0.41%), and TAR with no change. Of the total change in posterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -3.04% (2.42%), incision of the posterior lamella of the internal oblique with a change of -58.78% (0.39%), and TAR with a change of -38.17% (0.39%)., Conclusions and Relevance: In this case series, retrorectus dissection but not TAR was associated with reduced tension on the anterior fascia, suggesting that it should be performed if anterior fascial advancement is needed. Dividing the posterior lamella of the internal oblique aponeurosis and TAR was associated with reduced tension on the posterior fascia, suggesting that it should be performed for posterior fascial advancement.

Background: Tension-free abdominal closure is a primary tenet of laparotomy. But this concept neglects the baseline tension of the abdominal wall. Ideally, abdominal closure should be tailored to restore native physiologic tension. We sought to quantify the tension needed to re-establish the linea alba in patients undergoing exploratory laparotomy., Methods: Patients without ventral hernias undergoing laparotomy at a single institution were enrolled from December 2021 to September 2022. Patients who had undergone prior laparotomy were included. Exclusion criteria included prior incisional hernia repair, presence of an ostomy, large-volume ascites, and large intra-abdominal tumors. After laparotomy, a sterilizable tensiometer measured the quantitative tension needed to bring the fascial edge to the midline. Outcomes included the force needed to bring the fascial edge to the midline and the association of BMI, incision length, and prior lateral incisions on abdominal wall tension., Results: This study included 86 patients, for a total of 172 measurements (right and left for each patient). Median patient BMI was 26.4 kg/m 2 (IQR 22.9;31.5), and median incision length was 17.0 cm (IQR 14;20). Mean tension needed to bring the myofascial edge to the midline was 0.97 lbs. (SD 1.03). Mixed-effect multivariable regression modeling found that increasing BMI and greater incision length were associated with higher abdominal wall tension (coefficient 0.04, 95% CI [0.01,0.07]; p = 0.004, coefficient 0.04, 95% CI [0.01,0.07]; p = 0.006, respectively)., Conclusion: In patients undergoing laparotomy, the tension needed to re-establish the linea alba is approximately 1.94 lbs. A quantitative understanding of baseline abdominal wall tension may help surgeons tailor abdominal closure in complex scenarios, including ventral hernia repairs and open or burst abdomens., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Electrical synapses are neuronal gap junction (GJ) channels associated with a macromolecular complex called the electrical synapse density (ESD), which regulates development and dynamically modifies electrical transmission. However, the proteomic makeup and molecular mechanisms utilized by the ESD that direct electrical synapse formation are not well understood. Using the Mauthner cell of zebrafish as a model, we previously found that the intracellular scaffolding protein ZO1b is a member of the ESD, localizing postsynaptically, where it is required for GJ channel localization, electrical communication, neural network function, and behavior. Here, we show that the complexity of the ESD is further diversified by the genomic structure of the ZO1b gene locus. The ZO1b gene is alternatively initiated at three transcriptional start sites resulting in isoforms with unique N-termini that we call ZO1b-Alpha, -Beta, and -Gamma. We demonstrate that ZO1b-Beta and ZO1b-Gamma are broadly expressed throughout the nervous system and localize to electrical synapses. By contrast, ZO1b-Alpha is expressed mainly non-neuronally and is not found at synapses. We generate mutants in all individual isoforms, as well as double mutant combinations in cis on individual chromosomes, and find that ZO1b-Beta is necessary and sufficient for robust GJ channel localization. ZO1b-Gamma, despite its localization to the synapse, plays an auxiliary role in channel localization. This study expands the notion of molecular complexity at the ESD, revealing that an individual genomic locus can contribute distinct isoforms to the macromolecular complex at electrical synapses. Further, independent scaffold isoforms have differential contributions to developmental assembly of the interneuronal GJ channels. We propose that ESD molecular complexity arises both from the diversity of unique genes and from distinct isoforms encoded by single genes. Overall, ESD proteomic diversity is expected to have critical impacts on the development, structure, function, and plasticity of electrical transmission., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Michel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: We evaluated the impact of socioeconomic status on presentation, management, and outcomes of ventral hernias., Methods: The Abdominal Core Health Quality Collaborative was queried for adult patients undergoing ventral hernia repair. Socioeconomic quintiles were assigned using the Distressed Community Index (DCI): prosperous (0-20), comfortable (21-40), mid-tier (41-60), at-risk (61-80), and distressed (81-100). Outcomes included presenting symptoms, urgency, operative details, 30-day outcomes, and one-year hernia recurrence rates. Multivariable regression evaluated 30-day wound complications., Results: 39,494 subjects were identified; 32,471 had zip codes (82.2%).Urgent presentation (3.6% vs. 2.3%) and contaminated cases (0.83% vs. 2.06%) were more common in the distressed group compared to the prosperous group (p < 0.001). Higher DCI correlated with readmission (distressed: 4.7% vs prosperous: 2.9%,p < 0.001) and reoperation (distressed 1.8% vs prosperous: 0.92%,p < 0.001). Wound complications were independently associated with increasing DCI (p < 0.05). Clinical recurrence rates were similar at one-year (distressed: 10.4% vs prosperous: 8.6%, p = 0.54)., Conclusions: Inequity exists in presentation and perioperative outcomes for ventral hernia repair and efforts should be focused on increasing access to elective surgery and improving postoperative wound care., Competing Interests: Declaration of competing interest All authors have read and approved the manuscript. This manuscript is not under consideration elsewhere. This research was not funded. The authors have the following unrelated disclosures to report:, (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Patients with small- to medium-sized ventral hernias randomized to robotic enhanced-view totally extraperitoneal (eTEP) or robotic intraperitoneal onlay mesh (rIPOM) previously demonstrated comparable 30-day patient-reported outcomes. Here we report 1-year exploratory outcomes for this multi-center, patient-blinded randomized clinical trial., Study Design: Patients with midline ventral hernias 7 cm wide or less undergoing mesh repair were randomized to robotic eTEP or rIPOM. Planned exploratory outcomes at 1 year include pain intensity (using the Patient-Reported Outcomes Measurement Information System [PROMIS 3a]), Hernia-Related Quality of Life Survey (HerQLes) scores, pragmatic hernia recurrence, and reoperation., Results: One hundred randomized patients (51 eTEP, 49 rIPOM) reached a median 12-month follow-up (interquartile range 11 to 13) with 7% lost. After regression analysis adjusting for baseline scores, there was no difference in postoperative pain intensity at 1-year for eTEP compared with rIPOM (odds ratio [OR] 2.1 [95% CI 0.85 to 5.1]; p = 0.11). HerQLes scores were 15 points lower on average (ie less improved) at 1 year after eTEP repairs compared with rIPOM, a difference maintained after regression analysis (OR 0.31 [95% CI 0.15 to 0.67]; p = 0.003). Pragmatic hernia recurrence was 12.2% (6 of 49) for eTEP and 15.9% (7 of 44) for rIPOM (p = 0.834). In the first year, 2 eTEP and 1 rIPOM patients required reoperations related to their index repair (p = 0.82)., Conclusions: Exploratory analyses showed similar outcomes at 1 year in regard to pain, hernia recurrence, and reoperation. Abdominal wall quality of life at 1 year appears to favor rIPOM, and the possibility that an eTEP dissection is less advantageous in that regard should be the subject of future investigation., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

A wide array of mesh choices is available for abdominal wall reconstruction, making mesh selection confusing. Understanding mesh properties can make mesh choice simpler. Each mesh has characteristics that determine its durability, ability to clear an infection, and optimal position of placement in the abdominal wall. For clean retromuscular hernia repairs, we prefer bare, heavy weight, permanent synthetic mesh. For contaminated retromuscular abdominal wall reconstruction cases, such as parastomal hernia repairs, we typically use bare, medium weight, permanent synthetic mesh. Biologic and biosynthetic meshes also have acceptable wound event and hernia recurrence rates when used in contaminated cases., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Transfascial (TF) mesh fixation in open retromuscular ventral hernia repair (RVHR) has been advocated to reduce hernia recurrence. However, TF sutures may cause increased pain, and, to date, the purported advantages have never been objectively measured., Objective: To determine whether abandonment of TF mesh fixation would result in a noninferior hernia recurrence rate at 1 year compared with TF mesh fixation in open RVHR., Design, Setting, and Participants: In this prospective, registry-based, double-blinded, noninferiority, parallel-group, randomized clinical trial, a total of 325 patients with a ventral hernia defect width of 20 cm or less with fascial closure were enrolled at a single center from November 29, 2019, to September 24, 2021. Follow-up was completed December 18, 2022., Interventions: Eligible patients were randomized to mesh fixation with percutaneous TF sutures or no mesh fixation with sham incisions., Main Outcome and Measures: The primary outcome was to determine whether no TF suture fixation was noninferior to TF suture fixation for open RVHR with regard to recurrence at 1 year. A 10% noninferior margin was set. The secondary outcomes were postoperative pain and quality of life., Results: A total of 325 adults (185 women [56.9%]; median age, 59 [IQR, 50-67] years) with similar baseline characteristics were randomized; 269 patients (82.8%) were followed up at 1 year. Median hernia width was similar in the TF fixation and no fixation groups (15.0 [IQR, 12.0-17.0] cm for both). Hernia recurrence rates at 1 year were similar between the groups (TF fixation, 12 of 162 [7.4%]; no fixation, 15 of 163 [9.2%]; P = .70). Recurrence-adjusted risk difference was found to be -0.02 (95% CI, -0.07 to 0.04). There were no differences in immediate postoperative pain or quality of life., Conclusions and Relevance: The absence of TF suture fixation was noninferior to TF suture fixation for open RVHR with synthetic mesh. Transfascial fixation for open RVRH can be safely abandoned in this population., Trial Registration: ClinicalTrials.gov Identifier: NCT03938688.

Objectives: This paper about social media platforms of Swiss hospitals refers to the period between 10 February 2020 and 6 July 2020. The study included in-depth insights into the use of platforms, content analyses of posts and resonance of the posts. The study's objective was to get insights into social media post creation by and corresponding resonance in pandemic crisis., Study Design: This study included collection and analyses of posts created by a selection of Swiss hospitals during the period of study. All university hospitals and a variety of private and regional hospitals in all regions of Switzerland are represented. The data collection started before the official shutdown in Switzerland., Methods: This study used mixed method approach and content analysis to evaluate 2,326 posts during the study period related to the COVID-19 pandemic., Results: During the first phase of the pandemic, hospitals used social media platforms more frequently than normal. Especially in the first month, the number of posts rose disproportionally. The numbers dropped back to the initial situation after only 4 months into the COVID-19 pandemic. Most hospitals used Facebook and Twitter, whereas Instagram and YouTube's use were marginal. University hospitals used social media platforms differently than regional hospitals., Conclusion: Most posts generated only a very low response with a median of 2. Hospitals were therefore not able to create engagement of their followers. However, hospitals that publish actively were able to build a more active community. Only a small number of posts led to heated discussions in the comments. These viral posts shared information on the illness, the vaccination, children and COVID-19., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Prehospital chlorhexidine gluconate (CHG) skin washes are used to prevent wound complications, but little evidence supports this practice in hernia surgery. A propensity-matched retrospective review published by our group in 2016 found that prehospital CHG was associated with an increased risk of surgical site occurrences (SSO) and surgical site infections (SSI) after ventral hernia repair. Prehospital CHG was, therefore, abandoned by three of five surgeons at the Cleveland Clinic Foundation (CCF) by April 2017. We aimed to determine if discontinuation of prehospital CHG affected wound morbidity rates after incisional hernia repair., Methods: The Abdominal Core Health Quality Collaborative was queried for all patients who underwent open, clean incisional hernia repairs with 30-day follow-up from 2014 to 2019. Using an interrupted time series (ITS) analysis model adjusted for group and mean propensity score, wound morbidity before and after April 1, 2017 (start of Q2) was compared between three groups: CCF surgeons who abandoned prehospital CHG (Group 1), CCF surgeons who continued using prehospital CHG (Group 2), and non-CCF surgeons using prehospital CHG (Group 3). Outcomes included rates of SSOs, SSIs, and surgical site occurrences requiring procedural intervention (SSOPI) at 30 days., Results: In total, 4276 patients were included in the analysis (Group 1: 339 before Q2 vs 673 after Q2; Group 2: 211 before Q2 vs 175 after Q2; Group 3: 1312 before Q2 vs 1566 after Q2). Rates of SSO, SSIs, and SSOPIs at 30 days were similar across all three groups before and after prehospital CHG discontinuation., Conclusion: Stopping prehospital CHG wash did not result in increased wound morbidity after open, clean, incisional hernia repair. We have abandoned CHG use in this context., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Incisional hernia is the most common complication of midline laparotomy. Although obesity is a known risk factor, the incidence of hernia formation in obese patients is not well defined. We sought to define the rate of incisional hernia formation in obese patients undergoing primary midline laparotomy in a large academic medical center., Methods: Obese patients (BMI ≥ 30 kg/m 2 ) who underwent an elective or urgent primary midline laparotomy from 2017 to 2021 at our institution were retrospectively identified. A blinded hernia surgeon reviewed imaging to assess for incisional hernia formation, defined as a midline fascial defect with intra-abdominal contents herniated outside of the peritoneal cavity., Results: A total of 2241 patients met inclusion criteria. Cross-sectional imaging was available for 914 (41%) of these patients. The median BMI for all patients was 34.3 kg/m 2 (range 30.0-59.1). Median time to follow-up imaging was 316 days (181-957, IQR = 185) for all patients and 316 days (201-903, IQR = 184) for patients with incisional hernia. In total, 474 (51.9%) had radiographic evidence of an incisional hernia. Colorectal and General Surgery demonstrated the highest rate of incisional hernia (p < 0.001). During the study period, 138 patients (15.1%) underwent surgical repair of their hernia at our institution, with the highest percentage being Colorectal Surgery patients., Conclusion: There is a high rate of hernia formation and subsequent hernia repair in obese patients undergoing midline laparotomy. Most importantly, these findings demonstrate an immediate and pressing need to identify the patient risk factors and technical issues related to this rate of hernia formation., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)