Comparison of graft-reinforced repairs and suture repair using a novel biomechanical test.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine the feasibility of a novel biomechanical test for evaluating mesh-reinforced repair compared to suture-reinforced repair using an animal model. We hypothesized that the fatigue life of a mesh reinforced repair would be greater than that of xenograft reinforced repair and suture-only repair. METHODS: Wistar rats were randomly assigned to undergo a ventral hernia repair using sutures or one of the three mesh materials representative of incorporation, encapsulation and resorption host responses (Gynemesh, Pelvisoft and Surgisis®, respectively). All surviving animals were killed at 90 days and specimens containing the prosthesis-tissue interface were exposed to cyclic forces. The number of cycles to failure (fatigue life) was compared between groups using a Cox regression model. RESULTS: Of 40 randomly assigned animals, 11 died before 90 days. After randomizing an additional 5 rats, a total of 34 rats were killed at 90 days. The proportions of specimens that failed before 10,000 cycles were 25% (2/8), 50% (4/8), 62.5% (5/8) and 70% (7/10) in the Gynemesh, Surgisis, Pelvisoft, and suture control groups, respectively. In addition, the median number of cycles to failure was >10,000 in the Gynemesh group, >6,923 in the Surgisis group, 1133 in the Pelvisoft group and 741 in the control group. After adjustment for cross-sectional area, the risk of failure in the suture control group was higher than in all of the reinforced repair groups combined with an adjusted hazard ratio of 2.58 (95% CI 0.96 - 6.97), and was statistically significantly higher than in the Gynemesh group with an adjusted hazard ratio of 6.67 (95% CI 1.30 - 34.48). CONCLUSION: We present a novel biomechanical test that can be used to compare mesh materials in an animal model prior to use in humans. In this animal model, after adjusting for cross-sectional area, suture reinforced repair has a higher risk of failure than graft reinforced repair.

Comparison of levator ani muscle avulsion injury after forceps-assisted and vacuum-assisted vaginal childbirth.

OBJECTIVE: Using three-dimensional transperineal ultrasonography, we compared the prevalence of levator ani muscle injury after forceps with vacuum-assisted vaginal delivery. METHODS: This was a retrospective cohort study. Women who experienced at least one forceps delivery (across all deliveries) were compared with women who had at least one vacuum birth. On average, participants were 10 years from the index delivery. Three-dimensional transperineal ultrasound volumes were captured as cine loops at rest with Valsalva and with pelvic floor muscle contraction. The primary outcome was levator ani muscle avulsion. Secondary outcomes included hiatal diameter and area. Prevalence of pelvic floor disorders was also compared between the two delivery groups. RESULTS: Among 45 participants in the forceps group and 28 participants in the vacuum group, there were no differences between groups in maternal age at first delivery, parity, body mass index, birth weight, episiotomy, or duration of second stage. History of anal sphincter laceration was more common in the forceps group. The prevalence of levator ani muscle avulsion was significantly higher after forceps compared with vacuum delivery (22/45 [49%] compared with 5/28 [18%], P=.012, prevalence ratio 2.74, 95% confidence interval [CI] 1.17-6.40, odds ratio 4.40 [95% CI 1.42-13.62]). Controlling for delivery type, levator ani muscle avulsion was associated with symptoms of prolapse (P=.036), although objective evidence of prolapse was not significantly different between groups (P=.20). CONCLUSION: Ten years after delivery, the prevalence of levator avulsion is almost tripled after forceps compared with vacuum-assisted vaginal delivery. LEVEL OF EVIDENCE: II.

Vaginal childbirth and pelvic floor disorders.

Childbirth is an important event in a woman's life. Vaginal childbirth is the most common mode of delivery and it has been associated with increased incidence of pelvic floor disorders later in life. In this article, the authors review and summarize current literature associating pelvic floor disorders with vaginal childbirth. Stress urinary incontinence and pelvic organ prolapse are strongly associated with vaginal childbirth and parity. The exact mechanism of injury associating vaginal delivery with pelvic floor disorders is not known, but is likely multifactorial, potentially including mechanical and neurovascular injury to the pelvic floor. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist in clusters; hence, the isolated effect of these variables on the pelvic floor is difficult to study.

Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety.

BACKGROUND: Maternal cardiovascular and pulmonary events during labor and delivery may result in adverse maternal and fetal outcome. Potential etiologies include primary cardiac events, pulmonary embolism, eclampsia, maternal hemorrhage, and adverse medication events. Remifentanil patient-controlled analgesia is an alternative when conventional neuraxial analgesia for labor is contraindicated. Although remifentanil is a commonly used analgesic, its use for labor analgesia is not clearly defined. CASE PRESENTATION: We present an unexpected and unique case of remifentanil toxicity resulting in the need for an emergent bedside cesarean delivery. A 30-year-old G3P2 woman receiving subcutaneous heparin anticoagulation due to a recent deep vein thrombosis developed cardiopulmonary arrest during labor induction due to remifentanil toxicity. CONCLUSION: A rapid discussion among the attending obstetric, anesthesia, and nursing teams resulted in consensus to perform an emergent bedside cesarean delivery resulting in an excellent fetal outcome. During maternal cardiopulmonary arrest, a prompt decision to perform a bedside cesarean delivery is essential to avoid significant maternal and fetal morbidity. Under these conditions, rapid collaboration among obstetric, anesthesia, and nursing personnel, and an extensive multi-layered safety process are integral components to optimize maternal and fetal outcomes.