Intraoperative indocyanine green fluorescence angiography to predict wound complications in complex ventral hernia repair.

INTRODUCTION: Complex ventral hernia repair (VHR) is associated with a greater than 30% wound complication rate. Perfusion mapping using indocyanine green fluorescence angiography (ICG-FA) has been demonstrated to predict skin and soft tissue necrosis in many reconstructive procedures; however, it has yet to be evaluated in VHR. METHODS: Patients undergoing complex VHR involving component separation and/or extensive subcutaneous advancement flaps were included in a prospective, blinded study. Patients with active infection were excluded. ICG-FA was performed prior to incision and prior to closure, but the surgeon was not allowed to view it. An additional blinded surgeon documented wound complications and evaluated postoperative photographs. The operative ICG-FA was reviewed blinded, and investigators were then unblinded to determine its ability to predict wound complications. RESULTS: Fifteen consecutive patients were enrolled with mean age of 56.1 years and average BMI of 34.9, of which 60% were female. Most (73.3%) had prior hernia repairs (average of 1.8 prior repairs). Mean defect area was 210.4 cm2, mean OR time was 206 min, 66.6% of patients underwent concomitant panniculectomy, and 40% had component separation. Mean follow-up was 7 months. Two patients developed wound breakdown requiring reoperation, while 1 had significant fat necrosis and another a wound infection, requiring operative intervention. ICG-FA was objectively reviewed and predicted all 4 wound complications. Of the 12 patients without complications, 1 had an area of low perfusion on ICG-FA. This study found a sensitivity of 100% and specificity of 90.9% for predicting wound complications using ICG-FA. CONCLUSION: In complex VHR patients, subcutaneous perfusion mapping with ICG-FA is very sensitive and has the potential to reduce cost and improve patient quality of life by reducing wound complications and reoperation.

Staged hernia repair preceded by gastric bypass for the treatment of morbidly obese patients with complex ventral hernias.

BACKGROUND: Obesity may be the most predominant risk factor for recurrence following ventral hernia repair. This is secondary to significantly increased intra-abdominal pressures, higher rates of wound complications, and the technical difficulties encountered due to obesity. Medically managed weight loss prior to surgery is difficult. One potential strategy is to provide a surgical means to correct patient weight prior to hernia repair. METHODS: After institutional review board approval, we reviewed the medical records of all patients who underwent gastric bypass surgery prior to the definitive repair of a complex ventral hernia at our medical center. RESULTS: Twenty-seven morbidly obese patients with an average of 3.7 (range 1-10) failed ventral hernia repairs underwent gastric bypass prior to definitive ventral hernia repair. Twenty-two of the gastric bypasses were open operations and five were laparoscopic. The patients' average pre-bypass body mass index (BMI) was 51 kg/m2 (range 39-69 kg/m2), which decreased to an average of 33 kg/m2 (range 25-37 kg/m2) at the time of hernia repair at a mean of 1.3 years (range 0.9-3.1 years) after gastric bypass. Seven patients had hernia repair at the same time as their gastric bypass (four sutured, three biologic mesh), all of which recurred. Of the 27 patients, 19 had an open hernia repair and eight had a laparoscopic repair. Panniculectomy was performed concurrently in 15 patients who had an open repair. Prior to formal hernia repair, one patient required an urgent operation to repair a hernia incarceration and a small-bowel obstruction 11 months after gastric bypass. The average hernia and mesh size was 203 cm2 (range 24-1,350 cm2) and 1,040 cm2 (range 400-2,700 cm2), respectively. There have been no recurrences at an average follow-up of 20 months (range 2 months-5 years). CONCLUSION: Gastric bypass prior to staged ventral hernia repair in morbidly obese patients with complex ventral hernias is a safe and definitive method to effect weight loss and facilitate a durable hernia repair with a possible reduced risk of recurrence.

Surgical closure of end-stage palatal fistulas using anteriorly-based dorsal tongue flaps.

Effective closure of the recurrent palatal fistula demands proper diagnosis and anatomically-based classification, combined with an appreciation of surgical options. The anteriorly-based dorsal tongue flap is recommended to close large and/or compromised end-stage residual palatal fistula, provided that patient selection and surgical technique are meticulous. It has proved to be a safe and effective method of solving a difficult problem.

Spontaneous pneumothorax.

Spontaneous pneumothorax in the apparently healthy individual is a reasonably common occurrence. In a military hospital serving a large population in the age range most at risk for this entity, we have gained a wide experience with this problem. A review of our 10 year experience with spontaneous pneumothorax and its surgical treatment has been presented. In our series, a decreased male to female ratio was noted. This may reflect the increased incidence of female smokers. A total of 9.4 percent of our patients had complications of their tube thoracostomy treatment and an additional 10 percent required surgery for resolution of their problem. Our indications for pleural abrasion have been discussed. Pleural abrasion remains our mainstay of surgical therapy for treatment of recurrent spontaneous pneumothorax with acceptable morbidity.

Mucinous adenocarcinoma developing in chronic anal fistula: report of two cases and review of the literature.

Mucinous adenocarcinoma developing in a chronic anal fistula is a rare tumor of the anus of which there are less than 150 reported cases. There has been some debate as to whether the fistula is the source of the tumor, or whether the fistula is the presenting feature of a slow-growing, indolent carcinoma. Two recent cases seen at our hospital are presented, along with a review of the literature and what we feel to be strong evidence that the fistula and associated anal glands are indeed the source of this unusual tumor.