Bulging after DIEP Breast Reconstruction: New Insights Concerning Rectus Diastasis and Medial Perforator Harvest.

The aim of this study was to evaluate the association between flap harvest technique and occurrence of abdominal bulging. Methods: A retrospective analysis of 159 patients undergoing DIEP flap breast reconstruction between 2014 and 2021 in the University Medical Center Utrecht was conducted. Outcomes measured were preoperative rectus diastasis, flap weight, laterality of flap harvest (unilateral or bilateral), timing of the harvest (immediate or delayed), number of perforators harvested (single or multiple), and location of the harvested perforator (medial, lateral, or both). Results: In 159 patients, 244 DIEP flaps were performed, 16 of these donor-sites (6.6%) developed a clinically evident abdominal bulge. When preoperative rectus abdominis diastasis was found (n = 97), postoperative bulging occurred significantly more often (P < 0.01). Patients in whom the medial perforator artery was harvested for reconstruction (n = 114) showed less abdominal bulging than patients in whom the lateral (n = 92) was harvested (P = 0.02). Using single versus multiple perforators for the DIEP flap, bilateral versus unilateral reconstruction or timing of the operation showed no significant difference in outcome of bulging (P = 1.00, P = 0.78, P = 0.59, respectively). Conclusions: The incidence of bulging in our study cohort is comparable to the literature. Harvesting the medial perforator artery for the DIEP flap showed less abdominal bulging than using the lateral perforator artery in a DIEP flap breast reconstruction. Also, preoperative rectus diastasis was found to be an important risk factor for the occurrence of bulging.

Inter- and Intraobserver Agreement in Measuring Urolithiasis Density on Nonenhanced Computed Tomography.

Introduction: Treatment choice for urolithiasis is partially based on measuring stone density in HU on nonenhanced computed tomography (NECT). Interobserver variability in these measurements could have treatment consequences. This study aims to assess the observer agreement of measuring HU and whether the use of a protocol leads to a better agreement. Materials and Methods: We retrospectively included 155 consecutive NECTs of patients with stones ≥4 mm. Five observers (two radiologists, one urologist, one urology resident, and one radiology resident) assessed all anonymized NECTs four times in randomized order. HU was measured without instruction (rounds 1 and 2) and subsequently using two protocols (A and B, rounds 3 and 4). Protocols comprised using bone setting, zoom, and measuring HU without the penumbra, in either three (A) or one (B) axial plane. The inter- and intraobserver agreement was evaluated using the intraclass correlation coefficient (ICC). Results: Interobserver agreement on HU measurement without protocol was as follows: ICC = 0.84 (confidence interval [CI]: 0.79-0.87). Agreement diminished with protocol A, ICC = 0.62 (CI: 0.37-0.76), and improved with protocol B, ICC = 0.90 (CI: 0.86-0.92). Intraobserver agreement without protocol was ICC = 0.87, with protocol A, ICC = 0.87, and with protocol B, ICC = 0.93. The biggest improvement was seen for urologists' agreement from no protocol to protocol B, where ICC improved from 0.81 (CI: 0.70-0.87) to 0.91 (CI: 0.84-0.94). Conclusions: Observer agreement of HU measurement of urolithiasis without protocol is already good but using zoom, bone setting, and measuring in a representative plane is recommended. This protocol results in higher agreement, especially among urologists. Measuring in three axial planes does not increase agreement.

The evolution of trauma care in the Netherlands over 20 years.

INTRODUCTION: In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures). MATERIALS AND METHODS: In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated. RESULTS: It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement. CONCLUSION: Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential.

Timing of repair and mesh use in traumatic abdominal wall defects: a systematic review and meta-analysis of current literature.

Background: Traumatic abdominal wall hernias or defects (TAWDs) after blunt trauma are rare and comprehensive literature on this topic is scarce. Altogether, there is no consensus about optimal methods and timing of repair, resulting in a surgeon's dilemma. The aim of this study was to analyze current literature, comparing (1) acute versus delayed repair and (2) mesh versus no mesh repair. Methods: A broad and systematic search was conducted in PubMed, EMBASE, and the Cochrane Library. The selected articles were assessed on methodological quality using a modified version of the CONSORT 2010 Checklist and the Newcastle-Ottawa scale. Primary endpoint was hernia recurrence, diagnosed by clinical examination or CT. Random effects meta-analyses on hernia recurrence rates after acute versus delayed repair, and mesh versus no mesh repair, were conducted separately. Results: In total, 19 studies were evaluated, of which 6 were used in our analysis. These studies reported a total of 229 patients who developed a TAWD, of whom a little more than half underwent surgical repair. Twenty-three of 172 patients (13%) who had their TAWD surgically repaired developed a recurrence. In these studies, nearly 70% of the patients who developed a recurrence had their TAWD repaired primarily without a mesh augmentation and mostly during the initial hospitalization. Pooled analysis did not show any statistically significant favor for either use of mesh augmentation or the timing of surgical repair. Conclusion: Although 70% of the recurrences occurred in patients without mesh augmentation, pooled analysis did not show significant differences in either mesh versus no mesh repair, nor acute versus delayed repair for the management of traumatic abdominal wall defects. Therefore, a patient's condition (e.g., concomitant injuries) should determine the timing of repair, preferably with the use of a mesh augmentation.

Redesigning an International Orthopaedic CME Course: The Effects on Participant Engagement over 5 Years.

The time required to observe changes in participant evaluation of continuing medical education (CME) courses in surgical fields is unclear. We investigated the time required to observe changes in participant evaluation of an orthopaedic course after educational redesign using aggregate course-level data obtained from 1359 participants who attended one of 23 AO Davos Courses over a 5-year period between 2007 and 2011. Participants evaluated courses using two previously validated, 5-point Likert scales based on content and faculty performance, and we compared results between groups that underwent educational redesign incorporating serial needs assessment, problem-based learning, and faculty training initiatives (Masters Course), and those that did not (Non-Masters Course). Average scores for the usefulness and relevancy of a course and faculty performance were significantly higher for redesigned courses (p < 0.0001) and evaluations were significantly improved for both groups after faculty training was formalised in 2009 (p < 0.001). In summary, educational redesign incorporating serial needs assessment, problem-based learning, and faculty training initiatives were associated with improvement in participant evaluation, but these changes required 4-5 years to become evident.

A 5-Year Evaluation of the Implementation of Triple Diagnostics for Early Detection of Severe Necrotizing Soft Tissue Disease: A Single-Center Cohort Study.

BACKGROUND: The standardized approach with triple diagnostics (surgical exploration with visual inspection, microbiological and histological examination) has been proposed as the golden standard for early diagnosis of severe necrotizing soft tissue disease (SNSTD, or necrotizing fasciitis) in ambivalent cases. This study's primary aim was to evaluate the protocolized approach after implementation for diagnosing (early) SNSTD and relate this to clinical outcome. METHODS: A cohort study analyzing a 5-year period was performed. All patients undergoing surgical exploration (with triple diagnostics) for suspected SNSTD since implementation were prospectively identified. Demographics, laboratory results and clinical outcomes were collected and analyzed. RESULT: Thirty-six patients underwent surgical exploration with eight (22%) negative explorations. The overall 30-day mortality rate was 25%, with an early, SNSTD-related mortality rate of 11% (n = 3). Of these, one patient (4%) underwent primary amputation, but died during surgery. No significant differences between baseline characteristics were found between patients diagnosed with SNSTD in early/indistinctive or late/obvious stage. Patient diagnosed at an early stage had a significantly shorter ICU stay (2 vs. 6 days, p = 0.031). Mortality did not differ between groups; patients who died were all ASA IV patients. CONCLUSION: Diagnosing SNSTD using the approach with triple diagnostics resulted in a low mortality rate and only a single amputation in a pre-terminal patient in the first 5 years after implementation. All deceased patients had multiple preexisting comorbidities consisting of severe systemic diseases, such as end-stage heart failure. Early detection proved to facilitate faster recovery with shorter ICU stay.

Long-term follow-up after rib fixation for flail chest and multiple rib fractures.

PURPOSE: Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures. METHODS: All adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone. RESULTS: Of the 864 patients admitted with ≥ 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18-34) and 21 (IQR 16-29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62-1) and 0.79 (0.62-0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal. CONCLUSIONS: We show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.

Severely injured patients benefit from in-house attending trauma surgeons.

INTRODUCTION: There is continuous drive to optimize healthcare for the most severely injured patients. Although still under debate, a possible measure is to provide 24/7 in-house (IH) coverage by trauma surgeons. The aim of this study was to compare process-related outcomes for severely injured patients before and after transition of attendance policy from an out-of-hospital (OH) on-call attending trauma surgeon to an in-house attending trauma surgeon. METHODS: Retrospective before-and-after study using prospectively gathered data in a Level 1 Trauma Center in the Netherlands. All trauma patients with an Injury Severity Score (ISS) >24 presenting to the emergency department for trauma before (2011-2012) and after (2014-2016) introduction of IH attendings were included. Primary outcome measures were the process-related outcomes Emergency Department length of stay (ED-LOS) and time to first intervention. RESULTS: After implementation of IH trauma surgeons, ED-LOS decreased (p = 0.009). Time from the ED to the intensive care unit (ICU) for patients directly transferred to the ICU was significantly shorter with more than doubling of the percentage of patients that reached the ICU within an hour. The percentage of patients undergoing emergency surgery within 30 min nearly doubled as well, with a larger amount of patients undergoing CT imaging before emergency surgery. CONCLUSIONS: Introduction of a 24/7 in-house attending trauma surgeon led to improved process-related outcomes for the most severely injured patients. There is clear benefit of continuous presence of physicians with sufficient experience in trauma care in hospitals treating large numbers of severely injured patients.

Effectiveness of endoscopic totally extraperitoneal (TEP) hernia correction for clinically occult inguinal hernia (EFFECT): study protocol for a randomized controlled trial.

BACKGROUND: Groin pain is a frequent complaint in surgical practice with an inguinal hernia being at the top of the differential diagnosis. The majority of inguinal hernias can be diagnosed clinically. However, patients with groin pain without signs of an inguinal hernia on anamnesis or physical examination provide a diagnostic challenge. If ultrasonography shows a hernia that could not be detected clinically, this entity is called a clinically occult hernia. It is debatable if this radiological hernia is the cause of complaints in all patients with inguinal pain. The objective of this study is to assess whether watchful waiting is non-inferior to endoscopic totally extraperitoneal (TEP) inguinal repair in patients with a clinically occult inguinal hernia. METHODS: The EFFECT study is a multicenter non-blinded randomized controlled non-inferiority trial. Adult patients with unilateral groin pain and a clinically occult inguinal hernia are eligible to participate in this study. A total of 160 participants will be included and randomized to TEP inguinal hernia repair or a watchful waiting approach. The primary outcome of this study is pain reduction 3 months after treatment, measured by the Numeric Rating Scale (NRS). Secondary outcomes are quality of life, cost-effectiveness, patient satisfaction and crossover rate. Eight surgical centers will take part in the study. Participants will be followed-up for 1 year. DISCUSSION: This is the first large randomized controlled trial comparing treatments for patients with groin pain and a clinically occult inguinal hernia. To date, there are no interventional studies on the effect of surgery or a watchful waiting approach in terms of pain or quality of life in this subset of patients. A trial comparing the outcomes of the two approaches in patients with a clinically occult inguinal hernia is urgently needed to provide data facilitating the choice between the two treatment options. If watchful waiting is not inferior to surgical repair, costs of surgical repair may be saved. TRIAL REGISTRATION: The study protocol (NL61730.100.17) is approved by the Medical Ethics Committee (MEC-U) of the Diakonessenhuis, Utrecht, The Netherlands. The study was registered at the Netherlands Trial Registry ( NTR6835 ) registered on November 13, 2017.

Long-term Results of a Randomized Double-blinded Prospective Trial of a Lightweight (Ultrapro) Versus a Heavyweight Mesh (Prolene) in Laparoscopic Total Extraperitoneal Inguinal Hernia Repair (TULP-trial).

OBJECTIVE: The aim of the randomized clinical trial was to compare the 2 years of clinical outcomes of a lightweight (Ultrapro) vs a heavyweight (Prolene) mesh for laparoscopic total extraperitoneal (TEP) inguinal hernia repair. BACKGROUND: Lightweight meshes reduce postoperative pain and stiffness in open anterior inguinal hernia repair. The discussion about a similar benefit for laparoscopic repair is ongoing, but concerns exist about higher recurrence rates. METHODS: Between March 2010 and October 2012, male patients who presented with a primary, reducible unilateral inguinal hernia who underwent day-case TEP repair were eligible. Outcome parameters included chronic pain, recurrence, foreign body feeling, and quality of life scores. RESULTS: During the study period, 950 patients were included. One year postoperatively the presence of relevant pain (Numeric Rating Score 4-10) was significantly higher in the lightweight mesh group (2.9%) compared with the heavyweight mesh group (0.7%) (P = 0.01), and after 2 years this difference remained significant (P = 0.03). There were 4 (0.8%) recurrent hernias in the heavyweight mesh group and 13 (2.7%) in the lightweight group (P = 0.03). No differences in foreign body feeling or quality of life scores were detected. CONCLUSIONS: In TEP hernia surgery, there was no benefit of lightweight over heavyweight meshes observed 2 years postoperatively.

[European practice guidelines for the treatment of inguinal hernia: a summary]. / Europese richtlijn voor behandeling van liesbreuken: een samenvatting.

The European best practice guidelines on the treatment of inguinal hernia were published in 2009. Publications on this subject in international journals were updated in 2012. In patients with asymptomatic inguinal hernia or with minimal symptoms, conservative treatment is safe, but they do need to be informed that the risk for undergoing surgery increases by nearly 10% a year. Conservative treatment is less useful in younger patients. All adult men with symptomatic inguinal hernia need to undergo surgery. They should be treated with a technique in which a synthetic prosthesis (mesh) is used. The Lichtenstein technique is advised for the open treatment of inguinal hernia, since this is the most thoroughly evaluated technique. For endoscopic treatment, the European best practice guidelines advise the total extra-peritoneal technique. Nowadays the focus in complications is on the prevention of postoperative chronic pain.

Traumatic abdominal wall hernia, easily missed.

A 30-year-old male was diagnosed with a disruption of the musculofibrotic abdominal wall as a result of a blunt trauma 3 years after the injury. His traumatic abdominal wall hernia (TAWH) was initially missed on physical examination and computed tomography. The patient presented now with a lump in the left flank after a period of intended weight loss. Laparoscopic repair of the hernia resulted in being asymptomatic ever since. Missing a TAWH might have major consequences, such as incarceration and strangulation. Therefore, it is important to consider a TAWH after blunt abdominal trauma.

The proximal femur nail antirotation: an identifiable improvement in the treatment of unstable pertrochanteric fractures?

BACKGROUND: The optimal surgical treatment of patients with an unstable extracapsular proximal femoral fracture is yet to be found. From the biomechanical point of view, the use of an intramedullary device in combination with a dynamic femoral head/neck stabilization implant seems an optimal technique. One of these intramedullary devices, the Proximal Femoral Nail (PFN), has several drawbacks in practice. The Proximal Femur Nail Antirotation (PFNA) has been designed to address these. We hypothesized that the placement of one femoral head/neck fixation device in the PFNA would improve positioning of the implant in the femoral head compared with the PFN and reduce the number of reoperations in both short and long term. METHODS: We followed 157 consecutive patients with unstable trochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen classification 31.A.2 and A.3) treated with a PFN or a PFNA for 1 year. The radiologic position of the implant was evaluated, and the postoperative local and systemic complications were registered. RESULTS: The position of the femoral head/neck stabilization implant was "good" in 39 (44.8%) patients in the PFN group and 23 (32.9%) patients in the PFNA group; the position was "acceptable" in 30 (34.5%) versus 33 (47.1%) patients, and in 18 (20.7%) versus 14 (20%) patients, the position was "poor" (p = 0.277). Because of implant-related complications, three patients in the PFN group and four patients in the PFNA group needed an early reoperation (p = 0.136). A late reoperation because of implant-related complications was performed in 13 patients in the PFN group and in three in the PFNA group (p = 0.016). CONCLUSIONS: This study shows that osteosynthesis with the PFNA does not improve the position of the implant in the femoral head compared with the PFN. However, the risk of a secondary complication and the necessity of a late reoperation are significantly higher in patients treated with a PFN compared with patients treated with a PFNA.

Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair.

BACKGROUND: The long-term durability of laparoscopic repair of paraesophageal hiatal herniation is uncertain. This study focuses on the long-term symptomatic and radiologic outcome of laparoscopic paraesophageal herniation repair. METHODS: Between 2000 and 2007, 70 patients (49 females, mean age +/- standard deviation 60.6 +/- 10.9 years) undergoing laparoscopic repair of paraesophageal herniation were studied prospectively. After a mean follow-up of 45.6 +/- 23.8 months, symptomatic (65 patients, 93%) and radiologic follow-up (60 patients, 86%) was performed by standardized questionnaires and esophagograms. RESULTS: The symptomatic outcome was successful in 58 patients (89%), and gastroesophageal anatomy was intact in 42 patients (70%). The addition of a fundoplication was the only significant predictor of an unfavorable radiologic outcome in the univariate analysis (odds ratio .413; 95% confidence interval, .130 to 1.308; P = .125). CONCLUSIONS: The long-term symptomatic outcome of laparoscopic repair of paraesophageal hiatal herniation was favorable in 89% of patients, and 70% had successful anatomic repair. The addition of a fundoplication did not prevent anatomic herniation.

Regional trauma system reduces mortality and changes admission rates: a before and after study.

OBJECTIVE: To evaluate the effect of the introduction of a regionalized trauma system. BACKGROUND: Trauma systems have proven to be efficacious in reducing mortality in trauma patients in the United States. To date, this was not proven for inclusive trauma systems outside the United States. The current study evaluates the effect of the introduction of an inclusive trauma system in the Netherlands in 1999. METHODS: Retrospective pre- and post analyses of a trauma care system on hospital discharge data regarding trauma patients admitted to hospitals in the central region of The Netherlands. Patients treated during 1996 to 1998 (control group), before implementation of the inclusive trauma system were compared with patients treated during 2003 to 2005 (index group) after the trauma system was installed. Risk adjusted odds-ratios of death and admission to a trauma center were determined. RESULTS: A total of 33,201 patients were included in the control group and compared with 34,840 patients in the index group. After implementation of the trauma system, in-hospital mortality for all injured patients decreased from 2.6% to 2.3% (OR: 0.89 with 95% CI: 0.80-0.98). After adjustment for differences in gender, age, injury severity, comorbidity, injured body region, mechanism and intent of injury between both groups, the odds-ratio was 0.84 with 95% CI (0.76-0.94). Multitrauma patients were the subgroup admitted more frequently to a trauma center (OR: 1.19 with 95% CI: 1.01-1.39). CONCLUSIONS: Implementation of an inclusive trauma system in The Netherlands results in a more efficient triage system of trauma patients among hospitals and is associated with a substantial and statistically significant risk reduction (16%) of death.

Robot-assisted endoscopic surgery: a four-year single-center experience.

BACKGROUND: Robotic systems were introduced in the late 1990s with the objective to overcome the technical limitations of endoscopic surgery. In this prospective cohort study the potential safety, feasibility, pitfalls and challenges of robotic systems in gastrointestinal endoscopic surgery are assessed and our vision on future perspectives is presented. METHODS: Between August 2000 and December 2004, 208 procedures were performed with support of the Intuitive Surgical da Vincitrade mark robotic system. We started with cholecystectomies (40) and Nissen fundoplications (41) to gain experience with robot-assisted surgery. In the following years more complex procedures were carried out, i.e. colorectal procedures (7), type III/IV paraesophageal hernia repair (32), redo Nissen fundoplications (9), Heller myotomies (24), esophageal resections (22), rectopexies (16) and aortobifemoral bypasses (3). RESULTS: The median robotic set-up time was 13 min, and 7 min in the last 50 procedures. The median operating time for the total of procedures was 120 min (45-420) and the median blood loss was 30 ml (0-800). Fourteen procedures were converted to open surgery (6.7%). Equipment-related problems, such as start-up failures and positioning difficulties of the robotic arms, were encountered in 11 cases (5.3%). Postoperative complications were seen in 11 patients (11/176, 6.3%) after robot-assisted laparoscopic procedures. Pulmonary complications occurred in 11 patients, cardiac in 3, anastomic leakage in 3, chylous leakage in 3 and vocal cord paralysis in 3 after thoracoscopic esophagolymphadenectomy for esophageal cancer. One patient died 12 days after esophageal resection (0.5%). CONCLUSION: During the implementation of this robotic system, we experienced an obvious learning curve, particularly with regard to the positioning of the robot cart and communication between the surgeon and operating team. After 4 years, we have experienced that the merits of the current generation of this technology probably is preserved to complex endoscopic procedures with delicate dissection and suturing. In the nearby future we will focus on the treatment of motility disorders and malignancies of the esophagus and stomach. The position of the robot in the endoscopic operating room will have to be clarified by the outcome of prospective research. Furthermore, priorities have to be acclaimed on technical sophistication and cost reduction of these systems.