Association between cumulative surgeon experience and long-term outcomes in complex abdominal wall reconstruction.

PURPOSE: While many factors have been correlated with lesser outcomes in abdominal wall reconstruction (AWR), the impact of surgeon experience has yet to be elucidated. We sought to evaluate the effect of cumulative surgeon experience on long-term complex AWR outcomes. METHODS: We conducted a comprehensive review of all consecutive patients who underwent AWR using biologic mesh for the repair of ventral hernias or tumor resection defects from March 2005 to June 2019. The primary outcome measure was hernia recurrence (HR). Secondary outcomes were surgical site occurrences (SSOs) and surgical site infections (SSIs). Patients were a priori categorized into the following groups according to the cumulative number of hernia repairs performed by their surgeons: low (< 50), moderate experience (50-100), and high (> 100) experience. RESULTS: We identified 60 surgeons and 650 consecutive patients (62% women) who met our inclusion criteria. In adjusted models, AWR performed by surgeons with high experience was associated with a fourfold lower risk of HR (hazard ratio, 0.28; 95% confidence interval, 0.08 to 0.87), but the odds of surgical site occurrences (odds ratio, 0.72, 95% confidence interval, 0.34 to 1.52) and surgical site infections (odds ratio, 0.89, 95% confidence interval, 0.26 to 2.86) did not differ significantly in the high-experience group. CONCLUSIONS: High surgical experience, defined as > 100 cumulative hernia repairs, is predictive for markedly lower HR rates in complex AWR. These findings have potential implications for preoperative risk assessment, patient-centered surgeon selection, regulatory oversight, specific referral patterns, designations of centers of excellence, and individual provider or trainee quality improvement.

A porcine model for robotic training harvest of the rectus abdominis muscle.

Conventional open surgical approaches for the harvesting of the rectus abdominis muscle carry a high risk of morbidity. It is possible to reduce these risks by using laparoscopy or robot-assisted techniques. This work hypothesizes that a porcine model could be used for learning the robot-assisted collection of the rectus abdominis. The rectus abdominis was taken in 3 stages in 3 pigs: installation of the robot, surgical approaches with 4 trocars, dissection and collection of the muscle. The average operating time was 1h20min and the average muscular length was 16cm. Our results showed a learning curve for the robot-assisted harvesting of the rectus abdominis on a porcine model.

Robotic phrenic nerve harvest: a feasibility study in a pig model.

The aim of this study was to report on the feasibility of robotic phrenic nerve harvest in a pig model. A surgical robot (Da Vinci S™ system, Intuitive Surgical(®), Sunnyvale, CA) was installed with three ports on the pig's left chest. The phrenic nerve was transected distally where it enters the diaphragm. The phrenic nerve harvest was successfully performed in 45 minutes without major complications. The advantages of robotic microsurgery for phrenic nerve harvest are the motion scaling up to 5 times, elimination of physiological tremor, and free movement of joint-equipped robotic arms. Robot-assisted neurolysis may be clinically useful for harvesting the phrenic nerve for brachial plexus reconstruction.

Laryngeal sarcoidosis presenting as an isolated submucosal vocal fold mass.

Sarcoidosis can affect the larynx as a manifestation of systemic disease or as isolated laryngeal involvement. Classically, laryngeal involvement affects the supraglottis, and less commonly the subglottis, and true vocal fold involvement is rare. The clinical course is often highlighted by frequent exacerbations and remissions that, when associated with vague complaints and constitutional symptoms, are probably the greatest contributor to delayed presentation and diagnosis. We describe an unusual case of sarcoidosis that presented after a long and protracted clinical course as an isolated submucosal vocal fold mass requiring deep biopsy for diagnosis. A review of the literature with emphasis on diagnosis, appropriate airway management, and treatment is presented.

Basic FGF regulates interstitial collagenase gene expression in human smooth muscle cells.

Basic fibroblast growth factor (bFGF) is a mitogenic factor that is implicated in smooth muscle cell growth in atherosclerosis and vascular restenosis. In this study, we examined the effect of bFGF on the expression of the interstitial collagenase gene in human vascular smooth muscle cells. Results from Northern transfer analysis showed that bFGF increased collagenase mRNA levels greater than threefold as early as 24 h. Collagenase pre-mRNA levels were elevated approximately threefold by bFGF, according to RT-PCR analysis. Transient transfections of the smooth muscle cells with a 4.4-kb human collagenase promoter-CAT reporter gene, however, failed to show upregulation of the promoter activity by bFGF. Interestingly, transfections with deleted fragments containing promoter sequences from -1047 to -2271 resulted in modest stimulation of the collagenase-CAT promoter activity by bFGF, bFGF did not alter the stability of the collagenase mRNA, as demonstrated by degradation studies. The enhanced collagenase mRNA levels elicited by bFGF were reflected in increased amounts of collagenase protein that were detected by Western blot analysis. In summary, bFGF upregulates the interstitial collagenase expression, resulting in turnover of the extracellular matrix, an event that could facilitate smooth muscle cell migration and proliferation during the early stages of atherosclerosis and restenosis.