Open retrofascial incisional hernia repair is a safe and effective operation.

BACKGROUND: Incisional hernias occur in about ten percent of patient after elective abdominal operations. Although over 100,000 are performed annually in this country, the best method of repair remains controversial. We report the outcomes after a standardized approach by one surgeon. METHODS: The operation consisted of placement of polypropylene mesh beneath the fascia with fascial closure. A prospective database was maintained for the time period January, 1995, to June, 2014. All patients were followed for a minimum of six months postoperatively. RESULTS: There were 538 patients with a mean body mass index of 36.2 kg/m(2) and a mean defect size of 134.5 cm(2). There were 292 primary hernias with a recurrence rate of 2.7% and 246 recurrent hernias with a recurrence rate of 4.1% (P = .47). There was one death (.2%). Forty-three patients (8.0%) developed a wound complication, of which 17 (3.2%) were infections and the rest seromas. Only two patients required removal of the mesh. There were six patients admitted for postoperative small bowel obstruction, but only one in the immediate postoperative period. There were two enterocutaneous fistulas, both of which resolved nonoperatively. Five patients developed nonfatal pulmonary emboli. Mean length of stay decreased from an average of 4.0 days for the first 100 patients to 2.8 days for the subsequent patients. CONCLUSIONS: Retrofascial mesh repair for ventral incisional hernias has both low complication and recurrence rate. It should be considered the gold standard for such repairs.

Improving operating room efficiency via an interprofessional approach.

BACKGROUND: Third-party payer reimbursements will likely continue to decrease. Therefore, it is imperative for operating rooms (ORs), often a hospital's largest revenue source, to improve efficiency. We report the outcome after 3 years of a lean, Six Sigma program to improve OR utilization. METHODS: In January 2011, our hospital system instituted a facility-wide approach to address the problem of OR efficiency. Interprofessional teams were formed to examine all aspects of OR use. An OR Governance Committee consisting of Department Chairs, nursing and senior administration oversaw the project. RESULTS: Outpatients' readiness on time for surgery increased from 59% to 95%, while first case on-time starts improved from 32% to 73%. Block utilization went from 68% to 74% and actual room utilization improved from 56% to 68%. The number of cases increased by 9%. Overtime went from 7% of total to 4%, so personnel costs decreased 14% despite 26% more employees. There was a reduction in annual voluntary OR staff turnover from 28% to 11%. Revenues increased more than 10% annually. CONCLUSION: A concerted effort to optimize OR performance resulted in marked improvements in access, overall case efficiency, staff satisfaction, and financial performance.

The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center.

BACKGROUND: Diagnostic laparoscopy (DL) has decreased the rate of nontherapeutic laparotomy for patients suffering from penetrating injuries. We evaluated whether DL similarly lowers the rate of nontherapeutic laparotomy for patients with blunt injuries. METHODS: All patients undergoing DL over a 10-year period (ie, 2001-2010) in a single level 1 trauma center were classified by the mechanism of injury. Demographic and perioperative data were compared using the Student t and Fisher exact tests. RESULTS: There were 131 patients included, 22 of whom sustained blunt injuries. Patients suffering from blunt injuries were more severely injured (Injury Severity Score 18.0 vs 7.3, P = .0001). The most common indication for DL after blunt injury was a computed tomographic scan concerning for bowel injury (59.1%). The rate of nontherapeutic laparotomy for patients sustaining penetrating vs blunt injury was 1.8% and nil, respectively. CONCLUSIONS: DL, when coupled with computed tomographic findings, is an effective tool for the initial management of patients with blunt injuries.

Seatbelt triad: severe abdominal wall disruption, hollow viscus injury, and major vascular injury.

The triad of seatbelt-related severe abdominal wall disruption, hollow viscus injury, and distal abdominal aortic injury after a motor vehicle collision is uncommon. We present a small case series involving those three clinical features with the goal of preventing a future missed diagnosis of the distal abdominal aortic injury in particular.

Defining incidence and outcome of contrast-induced nephropathy among trauma: is it overhyped?

Contrast-induced nephropathy (CIN) in trauma patients is uncommon and the incidence is unknown. We studied the incidence of CIN and its outcome. A retrospective chart review of trauma patients 16 years of age and older who were admitted to our Level I trauma center during 2005 was performed. Patients who received the intravenous contrast CT scan and had their serum creatinine (Cr) monitored at admission and at 48 to 72 hours were identified. CIN was defined as a 0.5-mg/dL rise of serum Cr or a 25 per cent increase from the baseline if the baseline Cr was abnormal. We excluded patients transferred from an outside facility, patients without repeated serum Cr measurements, patients who had cardiac arrest or persistent hypotension, and patients who had received N-acetylcysteine (Mucomyst) before their CT scan. We compared CIN and non-CIN groups. During 2005, 543 fit our study criteria, of whom 19 (3.5%) had CIN. CIN (vs non-CIN) had a higher baseline serum Cr (1.48 + 0.23 vs 1.06 + 0.02, P < 0.001), a longer intensive care unit stay (17 vs 5 days, P < 0.001), and a longer hospital stay (19 vs 8 days, P < 0.001); the mortality rate was not different (10 vs 4%, P = 0.2). We found elevated baseline serum Cr (OR, 1.92; 95% CI, 1.13 to 3.27; P = 0.016) to be associated with increased risk for CIN. All but two serum Cr levels peaked within 48 hours; all returned to baseline. One patient with an underlying congenital kidney disease required temporary dialysis. CIN incidence in trauma is low and the clinical course is benign.

Abdominal wall injuries occurring after blunt trauma: incidence and grading system.

BACKGROUND: Traumatic abdominal wall injuries (AWIs) are being increasingly recognized after blunt force injury. METHODS: All available abdominal/pelvic computed axial tomography (CAT) scans of blunt trauma patients evaluated at our level I trauma center from January 2005 to August 2006 were reviewed for the presence of AWI. AWI was graded using a severity-based numeric system. AWI grade was then compared with variables from a prospectively maintained trauma registry. RESULTS: Of 1,549 reviewed CAT scans, 9% showed AWI (grade I = 53%, grade II = 28%, grade III = 9%, grade IV = 8%, and grade V = 2%). There was no association between AWI and seatbelt use, Injury Severity Score, weight, or need for abdominal surgery. CONCLUSIONS: AWI occurs in 9% of blunt trauma patients undergoing abdominal/pelvic CAT scans. The incidence of herniation on CAT at presentation after blunt trauma is .2%, and the incidence of patients at risk of future hernia formation is 1.5%. AWI can be effectively cataloged using a straightforward numeric grading system.

Traumatic flank hernias: acute and chronic management.

BACKGROUND: Traumatic flank hernias are increasingly recognized as occurring after severe blunt injury. To clarify the role and timing of operative therapy, we review here our recent experience. METHODS: A prospectively maintained database at Oklahoma's only level I trauma center was reviewed to identify all patients presenting with traumatic flank hernias. RESULTS: During the period from July 2001 through February 2007, 25 patients (.2% of all blunt trauma patients) had traumatic flank hernias. The average age was 36.4 years (range 13 to 66), and all cases but 1 were related to motor vehicle crashes. All patients had at least 1 associated injury. Repairs were done by standardized approach. Eleven patients underwent immediate surgery; 8 underwent delayed repair; and 3 underwent late repair (range 4.5 to 10 years after injury). The other 3 patients were managed expectantly. There was 1 mortality and 3 recurrences. Length of stay for acute trauma ranged from 5 to 49 days and was dependent on the severity of associated injuries. Follow-up of 21 patients ranged from 7 to 710 days. CONCLUSIONS: Traumatic flank hernias are rare but more common than previously recognized. Prompt recognition, proper timing, and technique are key to successful outcomes.

Retrofascial mesh repair of ventral incisional hernias.

BACKGROUND: Recurrence rates after ventral incisional hernia repair are reported to be as high as 33% and are associated with considerable morbidity and lost time. The purpose of this study was to determine if retrofascial mesh placement reduces the incidence of recurrence as well as the severity of wound infections. METHODS: A prospective database covering the period from January 1995 to June 2003 was maintained. All patients underwent a standardized technique by a single surgeon. Polypropylene mesh was placed between the fascia and the peritoneum with the fascia closed over the mesh. RESULTS: There were 150 patients (126 women, 24 men) with a mean age of 55 years. Their average weight was 88 kg, with an average body mass index of 32. Sixty-three (42%) of the hernias were recurrences of a previous repair. The average size of the hernia was 8 x 14 cm. There was 1 postoperative mortality. There was a 9% postoperative infection rate with 2 patients (1%) requiring mesh removal. Long-term follow-up evaluation has revealed 3 recurrences (2%) and 3 readmissions for bowel obstruction with 1 patient requiring surgical release. There were no fistulas noted. CONCLUSIONS: Incisional hernia repair with mesh placed in the retrofascial position decreases both the risk for recurrence and the severity of wound infection without significant problems from bowel obstruction or enteric fistula.

The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis.

OBJECTIVE: To examine the utility of magnetic resonance cholangiography (MRC) in the preoperative evaluation of patients with gallstone pancreatitis. SUMMARY BACKGROUND DATA: Gallstone pancreatitis is often associated with the presence of common bile duct (CBD) stones that may require endoscopic removal prior to planned laparoscopic cholecystectomy. No reliable clinical criteria exist, however, that can accurately predict CBD stones and the need for preoperative endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Sixty-four patients were identified with gallstone pancreatitis based on clinical presentation and imaging studies over a three-and-a-half-year period. All patients underwent MRC, and the images were evaluated for gallstones, CBD stones, cholecystitis, and pancreatitis RESULTS: Seventeen of the 64 patients (27%) with gallstone pancreatitis were found to have CBD stones confirmed by ERCP. MRC correctly predicted CBD stones in 16 of the 17 patients (sensitivity = 94%). In 1 additional patient, MRC demonstrated CBD stones not seen at ERCP, consistent with probable passage. By comparison, the sensitivities of other criteria for predicting CBD stones were (1) elevated bilirubin >or=2.0 mg/dL = 65%; (2) dilated duct on ultrasound = 55%; and (3) CBD stones on ultrasound = 27%. MRC was able to visualize gallbladder stones in 57 of 62 patients (94%) and correctly predicted acute cholecystitis in 6 of 8 patients. MRC also detected peripancreatic edema and inflammatory changes consistent with acute pancreatitis in 45 of 64 patients (70%). CONCLUSIONS: These results demonstrate that MRC can accurately identify CBD stones preoperatively in patients with gallstone pancreatitis and provide valuable information with respect to other biliary pathology, including cholelithiasis, acute cholecystitis, and pancreatitis. MRC is an effective noninvasive screening tool for CBD stones, appropriately selecting candidates for preoperative ERCP and sparing others the need for an endoscopic procedure with its associated complications.

Factors influencing outcome in delayed primary closure of contaminated abdominal wounds: a prospective analysis of 181 consecutive patients.

Delayed primary closure (DPC) is an accepted method in the management of contaminated abdominal wounds. Clinical factors predicting its success have not been studied. Over a 14-year period 181 patients presenting to a single surgeon with Class IV abdominal wounds were managed by a standardized protocol. Initial saline gauze packing was left undisturbed until the wound was visually inspected on postoperative day 3. Clean wounds were closed using SteriStrips. Visible purulence was managed by dressing changes. There were 103 males and 78 females with an average age of 48.5 years (range, 11-92 years). DPC was performed on 144 patients of whom four (2.8%) developed wound infections. The factors associated with the development of wound pus before DPC in the remaining patients were: requirement for mechanical ventilation for more than 72 hours, presence of severe pre-existing systemic disease, and trauma. Other diagnoses, length and type of incision, and presence of shock had no effect on outcome. An intra-abdominal abscess developed in 11 patients with early wound purulence versus none in those undergoing DPC (P < 0.001). DPC is a safe wound management technique that can be effectively applied in the large majority of patients with dirty abdominal wounds. The appearance of wound purulence before DPC is a harbinger that identifies those patients at risk for late intra-abdominal infections.

Increased laparoscopic experience does not lead to improved results with acute cholecystitis.

BACKGROUND: As laparoscopic experience increases, ever more challenging cases are attempted. Enlarged surgeon experience, along with better technology, has been lauded as improving outcomes. The purpose of this study is to see if this applies to the management of acute cholecystitis. METHODS: We reviewed our experience over a 7 and a half year period. Information was obtained from a prospectively maintained computer database containing patient presentation, demographics, workup, laboratory values, and outcomes. Diagnosis of gangrene was based on pathologic examination of the specimen. RESULTS: There were 305 patients admitted to our institution with acute cholecystitis. Group I (n = 111) was admitted during the first half of the study and group II (n = 194) during the second half. Demographics were similar in the two groups. While slightly more patients were attempted laparoscopically in group II (90% versus 82%), conversion rates were virtually identical (27.1% versus 27.5%). There was a trend toward improved results with group II versus group I in mortality (3% versus 4%) and morbidity (14% versus 21%; P = not significant). Deaths were divided between sepsis and cardiac events. Gangrenous cholecystitis was less frequent in group II patients (29% versus 40%; P = 0.06). Analysis of gangrene versus non-gangrene patients within each group showed that conversion rates remained twice as high (40% versus 20%; P < 0.05) in those with gangrene. Interestingly, gangrene had no effect on morbidity or mortality. CONCLUSIONS: Morbidity and mortality for acute cholecystitis remain relatively high. These seem to be determined by the degree of acute and chronic illness present at the time of diagnosis. As conversion rates remain unchanged, increased surgeon experience and further advances in laparoscopic technology are unlikely to dramatically affect results. Efforts to improve outcomes for this common disease should therefore focus on better and earlier identification of patients for operation.