Does prophylactic biologic mesh placement protect against the development of incisional hernia in high-risk patients?

BACKGROUND: The purpose of this study was to determine whether the prophylactic use of a biologic prosthesis protects against the development of incisional hernia in a high-risk patient population. METHODS: A prospective, nonrandomized trial was conducted on 134 patients undergoing open Roux-en-Y gastric bypass by a single surgeon, at two institutions, from January 2005 to November 2007. At Hospital A, all patients (n=59) underwent fascial closure of the abdominal midline wound with the prophylactic placement of a biologic mesh (AlloDerm®) in an in-lay fashion. Patients at Hospital B (n=75) underwent primary abdominal wall closure using #1 PDS in a running fashion. Data collected included patient demographics, abdominal wall closure technique, postoperative wound complications, follow-up period, and incidence of incisional hernia. RESULTS: During the study period 134 patients (mean age=40.4 years, 80.7% female) underwent open Roux-en-Y gastric bypass (59.7% mesh, 41.5% nonmesh). Twenty-eight patients were excluded from the analysis secondary to a short follow-up period (mesh=13, nonmesh=11) and/or reoperative surgery unrelated to the development of an incisional hernia (mesh=2, nonmesh=2). The mean follow-up period was 17.3±8.5 months. The overall incidence of incisional hernia was 11.3% (95% CI: 5.2-17.45). The incidence of incisional hernia was significantly lower in the mesh group versus the nonmesh group (2.3 vs. 17.7%, P=0.014). In a multivariate logistic regression model that adjusted for age, sex, body mass index, albumin, smoking, diabetes, prior surgery, seroma formation, weight loss, and mesh placement, the development of incisional hernia was found to be associated with smoking (adjusted odds ratio [OR] 8.46, 95% CI: 1.79-40.00, P=0.007) while prophylactic mesh was noted to be protective against hernia development (adjusted OR 0.06, 95% CI: 0.006-0.69, P=0.02). CONCLUSION: The prophylactic use of biologic mesh for abdominal wall closure appears to reduce the incidence of incisional hernia in patients with multiple risk factors for incisional hernia development.

Minimally invasive repair of post-pneumonectomy syndrome.

We report on a 42-year-old female who underwent right pneumonectomy for hemoptysis from an aspergilloma cavity. Several years postoperatively she complained of increasing shortness of breath, wheezing, and dyspnea upon exertion. Chest computed tomography showed a counterclockwise rotation of the mediastinum with obstruction of the left lower lobe bronchus. Minimally invasive repair was carried out using an intrapleural tissue expander for dissection and an adjustable saline prosthesis for mediastinal centralization. Intraoperative bronchoscopy showed complete resolution of the left lower lobe bronchial obstruction, and postoperatively her symptoms resolved completely. This is the first reported case of a minimally invasive approach for the treatment of post-pneumonectomy syndrome in the United States.

Comparison of the sensitivity of physical and virtual laparoscopic surgical training simulators to the user's level of experience.

BACKGROUND: The recent focus on quality of care and patient safety has been accompanied by increased interest in standardizing the training for laparoscopic surgeons. Studies have shown that laparoscopic simulators can be used to train surgical skills. Therefore, we designed an experiment to compare the effectiveness of two popular training systems. One system was based on a physical model, whereas the other used a virtual reality model. METHODS: A total of 32 medical students and residents were tested on both simulators. Time required for task completion and number of errors committed were recorded and compared. RESULTS: The physical training system differentiated among experience levels on three of the five tasks when time was used as a measure and four of five tasks when score was used, whereas the virtual reality system yielded statistically significant results in eight of 13 tasks for time and in five of 13 tasks for score. CONCLUSION: The physical model is more sensitive than the virtual reality one in detecting differences in levels of laparoscopic surgical experience.

Mesenteric traction syndrome or gut in distress.

The mesenteric traction syndrome (MTS) remains, seventeen years after its first designation as a distinct pathologic entity, an aspect of surgical practice that has received limited attention. Apart from its symptomatology, there is mostly speculation about its exact causes and pathophysiologic mechanisms. Even though full-blown MTS is rather rare, the advent of laparoscopic surgery has indicated that there are different stages of stress associated with open abdominal surgery. Some evidence points to the involvement of mast cell derived vasoactive mediators and suggests possible pharmacologic management.

Malignant neoplasms: discordance between clinical diagnoses and autopsy findings in 3,118 cases.

BACKGROUND: During the past few decades, hospital autopsy rates have steadily declined throughout the Western world. This decline is mainly attributed to the introduction of advanced diagnostic techniques. Despite technological developments, discrepancy rates between clinical diagnoses and autopsy findings remain high. Few studies have addressed discrepancy rates exclusively with regard to malignant neoplasms. In the present study, we reviewed the records of 3,118 autopsies performed at Mayo Clinic during a 6-year period (1994-1999) and identified clinically undiagnosed malignancies found at autopsy and clinically diagnosed cancers not confirmed at postmortem examination. MATERIALS AND METHODS: Autopsy protocols, provisional and final anatomic diagnoses, and data from the Mayo Autopsy Pathology Quality Assurance program were reviewed in an attempt to identify discrepancies between clinical diagnoses and autopsy findings regarding malignant neoplasms. RESULTS: In 3,118 autopsies performed at Mayo Clinic between 1994 and 1999, a malignant tumor was identified in 768 cases (25%). In 128 of 3,118 cases (4.1%), the malignancy was not diagnosed clinically. In 14 of 3,118 cases (0.45%), autopsy failed to confirm a clinically diagnosed cancer. A review of the literature is presented. CONCLUSIONS: Autopsy remains an effective tool for the confirmation and refutation of clinical diagnostic findings regarding malignant neoplasms.