Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons.

BACKGROUND: No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. METHODS: A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. RESULTS: Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. CONCLUSIONS: Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

Prospective, comparative study of postoperative quality of life in TEP, TAPP, and modified Lichtenstein repairs.

INTRODUCTION: The purpose of this study was to compare postoperative quality of life (QOL) in patients undergoing laparoscopic totally extraperitoneal (TEP), transabdominal preperitoneal (TAPP), or modified Lichtenstein (ML) hernia repairs. METHODS: The International Hernia Mesh Registry (2007-2010) was interrogated. 2086 patients who underwent 2499 inguinal hernia repairs were identified. A Carolinas Comfort Score was self-reported at 1-, 6-, 12-months and results were compared. Subgroups analysis and logistic regression were used to identify confounders and to control for significant variables. RESULTS: One hundred seventy-two patients met the exclusion criteria. The distribution of unilateral procedures was TEP (n = 217), TAPP (n = 331), and ML (n = 953). Average follow-up was 12 months. Use of >10 tacks, lack of prostate pathology, recurrent hernia repairs, and bilateral hernia repairs were significant predictors of postoperative pain. One month after surgery 8.9%, 16.6%, and 16.5% were symptomatic for TEP (P = 0.038 vs. ML), TAPP and ML, respectively. At 6 months and 1 year no differences were observed. The number of tacks used varied significantly, with 18.1% of TAPP and 2.3% of TEP with >10 tacks (P = 0.005). The incidence of hernia recurrences were equivalent: TEP (0.42%), TAPP (1.34%), and ML (1.27%). The number or type of tacks utilized did not impact recurrence rates. CONCLUSION: Use of >10 tacks doubles the incidence of early postoperative pain while having no effect on rates of recurrence. There was no difference in chronic postoperative pain comparing ML, TEP, and TAPP including when controlled for tack use.