Surgical aspects and early morbidity of patients undergoing open recurrent inguinal hernia repair.

PURPOSE: This study aims to characterize the patterns of recurrence associated with specific types of primary inguinal hernia repair techniques used for and their respective correlations with early morbidity, in patients undergoing open repair for their first hernia recurrence. METHODS: After ethics approval was obtained, a retrospective review of charts from patients who underwent open surgery for repair of a first recurrence after a previous inguinal hernia repair during 2013-2017 was completed. Statistical analyses were performed and p-values < .05 are reported as statistically significant. RESULTS: 1393 patients underwent 1453 surgeries for recurrent inguinal hernias at this institution. Operations for recurrence were longer (61.9 ± 21.1 vs. 49.3 ± 11.9; p < .001), required more frequent intra-operative surgical consultation (1% vs. 0.2%; p < .001) and had a higher incidence of surgical-site infections (0.8% vs. 0.4%; p = .03) than primary inguinal hernia repairs. When comparing the patterns of recurrence among different techniques of primary repairs, patients undergoing laparoscopic hernia repair presented with a higher incidence of indirect recurrences. Reoperations after a Shouldice repair and open mesh repair represented markers for higher surgical difficulty in the recurrent operation (longer operative time, higher identification of heavy scarring, less nerve identification, and higher frequency of intra-operative consultation), but not higher rates of complications when compared with other techniques. CONCLUSIONS: Open reoperations for inguinal hernia first recurrences are more complex, with noticeable differences according to the index operation, and associated with higher morbidity when compared with primary hernia repairs. This complexity varies according to the type of primary surgery, with a previous Shouldice repair and open hernia repair with mesh presenting higher surgical difficulties although this did not translate to higher incidence of early complications. This information may allow adequate allocation of surgeons with an expertise in recurrent hernias and choice of recurrent repair method (laparoscopic or open) based on the primary surgery.

The incidence of occult paraumbilical hernias in patients undergoing primary umbilical hernia repair.

PURPOSE: The primary goal of this study was to determine the incidence of occult paraumbilical hernias during open primary umbilical hernia repair. The secondary objective was to further characterize the clinical features of these patients and hernias. METHODS: This was a retrospective chart review of patients undergoing primary umbilical hernia repair at Shouldice Hospital, from 2007 to 2017. Inclusion criteria were utilized to elucidate patients, where a concomitant occult paraumbilical hernia was found. Descriptive statistics were used throughout. RESULTS: 5850 patients underwent primary umbilical hernia repair, 459 (7.85%) patients had concomitant primary umbilical and paraumbilical hernias. There was a preoperative suspicion/diagnosis of a paraumbilical hernia in 166 (2.8%) of these patients. In 293 (5.01%) patients who had open primary umbilical hernia repair, at least one associated occult paraumbilical defect was found during surgery. Most of umbilical and concomitant occult paraumbilical hernias were small and medium size defects. The great majority of the reported occult paraumbilical hernias were found in the supraumbilical position at a distance of 3 cm or less from the top of the umbilical defect. CONCLUSION: The incidence of concomitant occult paraumbilical hernias in patients mildly overweight undergoing primary umbilical hernia repair is 5.01%, relevant to surgical decision-making. Since the great majority of these paraumbilical defects are superior to the umbilical defect, an adequate incision and dissection for at least 3 cm above the umbilical hernia may reduce the number of missed concomitant hernias and result in less presumed recurrences.

Systematic review to establish absolute standards for technical performance in surgery.

BACKGROUND: Standard setting allows educators to create benchmarks that distinguish between those who pass and those who fail an assessment. It can also be used to create standards in clinical and simulated procedural skill. The objective of this review was to perform a systematic review of the literature using absolute standard-setting methodology to create benchmarks in technical performance. METHODS: A systematic review was conducted by searching MEDLINE, Embase, PsycINFO and the Cochrane Database of Systematic Reviews. Abstracts of retrieved studies were reviewed and those meeting the inclusion criteria were selected for full-text review. The quality of evidence presented in the included studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI), where a score of 14 or more of 18 indicates high-quality evidence. RESULTS: Of 1809 studies identified, 37 used standard-setting methodology for assessment of procedural skill. Of these, 24 used participant-centred and 13 employed item-centred methods. Thirty studies took place in a simulated environment, and seven in a clinical setting. The included studies assessed residents (26 of 37), fellows (6 of 37) and staff physicians (17 of 37). Seventeen articles achieved a MERSQI score of 14 or more of 18, whereas 20 did not meet this mark. CONCLUSION: Absolute standard-setting methodologies can be used to establish cut-offs for procedural skill assessments.

Consensus-based training and assessment model for general surgery.

BACKGROUND: Surgical education is becoming competency-based with the implementation of in-training milestones. Training guidelines should reflect these changes and determine the specific procedures for such milestone assessments. This study aimed to develop a consensus view regarding operative procedures and tasks considered appropriate for junior and senior trainees, and the procedures that can be used as technical milestone assessments for trainee progression in general surgery. METHODS: A Delphi process was followed where questionnaires were distributed to all 17 Canadian general surgery programme directors. Items were ranked on a 5-point Likert scale, with consensus defined as Cronbach's α of at least 0·70. Items rated 4 or above on the 5-point Likert scale by 80 per cent of the programme directors were included in the models. RESULTS: Two Delphi rounds were completed, with 14 programme directors taking part in round one and 11 in round two. The overall consensus was high (Cronbach's α = 0·98). The training model included 101 unique procedures and tasks, 24 specific to junior trainees, 68 specific to senior trainees, and nine appropriate to all. The assessment model included four procedures. CONCLUSION: A system of operative procedures and tasks for junior- and senior-level trainees has been developed along with an assessment model for trainee progression. These can be used as milestones in competency-based assessments.

Influence of endosperm vitreousness and kernel moisture at harvest on site and extent of digestion of high-moisture corn by feedlot steers.

Six ruminally and duodenally cannulated Angus-Jersey crossbred steers (450 kg of BW) were used in a 6 x 6 Latin square to evaluate the effect of kernel vitreousness and moisture on intake and digestibility of high-moisture corn. Arranged in a 2 x 3 factorial, diets included a floury (FLO) or a vitreous (VIT) endosperm corn hybrid harvested at 28.1% (DRY), 31.2% (MID), or 35.7% (WET) kernel moisture content. Diet DM consisted of 88.25% high-moisture corn, 6% chopped alfalfa hay, 2% corn gluten meal, 0.75% urea, and 3% supplement. Supplement was included to ensure that the diets contained a minimum (DM basis) of 0.6% Ca, 0.6% K, 0.2% S, 33 mg/kg of monensin, and 11 mg/kg of tylosin. Geometric mean diameter of lyophilized high-moisture corn tended to be less (P = 0.06) for VIT than for FLO, and the calculated particle surface area was 15.8% greater (P = 0.03). An interaction of vitreousness with the quadratic effect of moisture was noted (P < 0.001), such that fraction a and effective degradation for starch tended to be greater for the vitreous hybrid at the least and greatest moisture content but lower for the vitreous hybrid at the intermediate moisture content. Intake and ruminal disappearance of DM, OM, and starch were not influenced by vitreousness or moisture, with ruminal starch disappearance averaging 90.9%. Intestinal starch digestion measured as a percentage of starch entering the intestines averaged 91% and was greater (P < 0.05) for VIT than FLO corn. Averaged across moisture levels, total tract starch digestibility was greater (P < 0.003) for VIT than FLO. Compared with FLO kernels, VIT kernels appeared to be more brittle and therefore shattered more readily when rolled, particularly at the driest kernel moisture level. Furthermore, increased surface area of smaller particles may have been responsible for the greater starch utilization from VIT corn. In contrast with the results from other in situ and in vivo trials with dry-rolled corn grain, in which the starch from vitreous hybrids was less rapidly or completely digested, hybrids with more vitreous starch, when fed as high-moisture corn, had greater total tract starch digestibility, primarily due to greater postruminal starch digestion.

Effect of a saponin-based surfactant and aging time on ruminal degradability of flaked corn grain dry matter and starch.

The objectives of this study were to investigate the effect of a saponin-based surfactant, Grain Prep surfactant (GP), and hot flake aging time on starch characteristics and ruminal DM and starch degradability of steam-flaked corn grain. In 2 experiments, the moisture content of incoming corn was automatically adjusted using the Grain Prep Auto Delivery System to 19.8% (Exp. 1) and 18.5% (Exp. 2). The application rate of GP was 22 mg/kg (as-is basis). Control corn was treated with water alone. Processed corn in Exp. 2 was stored in insulated containers for 0, 4, 8, or 16 h. Flaked corn samples were incubated in the rumen of lactating dairy cows for 0, 2, 4, 6, 16, or 24 h. In Exp. 1, GP increased, compared with the control, the soluble fraction and effective degradability (ED) of DM by 17.2 and 8.6%, respectively. The ED of cornstarch was increased by 6.7%. In Exp. 2, the concentration of soluble DM and starch were increased by GP by 15 and 24% compared with the control. The ED of DM and starch were also increased by 3 and 4%, respectively. No differences in gelatinization temperatures were observed due to treatment, except that GP-treated grain had a slightly greater mean gelatinization enthalpy in Exp. 2. In a pilot study, DM degradability parameters were not affected by germination of the corn kernels. Aging of the hot flakes for up to 16 h resulted in a quadratic decrease in DM and starch ruminal degradability. The aging process affected starch gelatinization enthalpy values of flaked grain in a manner opposite to that observed for ruminal DM and starch degradation. This phenomenon was most likely explained by increased starch intramolecular associations or crystallinity associated with starch annealing, or both. This study confirmed our previous observations that Grain Prep surfactant increases flaked corn DM and starch degradability in the rumen. Because the rate of degradation was not affected by the surfactant, the increase in degradability was attributed mainly to increases in DM and starch solubility.

Effects of pasteurization of potato slurry by-product fed in corn-or barley-based beef finishing diets.

Pasteurization of vegetable by-products such as potato slurry (PS) before feeding may be necessary to prevent the spread of pathogens and beef carcass blemishes. We hypothesized that pasteurization would increase ruminal fermentability of PS starch. Four ruminally cannulated crossbred beef steers (initial BW = 432) were used in a 4 x 4 Latin square experiment with a 2 x 2 factorial arrangement of treatments to examine the main effects and interactions of pasteurization (54.4 degrees C for 2 h) of PS and grain type (GT; dry-rolled corn and barley) on ruminal and total tract digestion of beef finishing diets. Diets contained 7% alfalfa hay and 14% PS (DM basis) and were fed ad libitum three times daily. Corn-based diets had 71.7% corn, whereas barley-based diets had 60% barley and 11.7% corn. Pasteurization resulted in greater (P = 0.004) soluble, rapidly degradable starch (34.3 vs. 26.7% for pasteurized and nonpasteurized PS, respectively). Ruminal fluid pH was more acidic (P < 0.07) for corn-based diets than for barley-based diets (P = 0.07) at 0200 and 2100 (sample time x GT; P < 0.05). Ruminal fluid pH was more acidic (P = 0.06) at 1400 for corn-based diets containing pasteurized PS compared with other dietary treatments (sample time x pasteurization x GT; P = 0.04). Minimum and maximum ruminal pH were greater (P < 0.10) for barley-based diets than for corn-based diets. Ruminal fluid pH was < 6.0 for a greater (P = 0.04) proportion of the day for corn-based compared with barley-based diets. In vitro incubation measurements revealed that pasteurization of PS resulted in lower (P = 0.06) ruminal fluid ammonia N concentration. Ruminal fluid ammonia N concentration was lower (P = 0.11) for barley-based diets than for corn-based diets. Steers fed barley-based diets had greater (P = 0.02) DMI and lesser (P < 0.05) total tract digestibility of DM and ADF compared with steers fed corn diets. Pasteurization increased (P = 0.10) total tract starch digestibility. Results indicate pasteurization increased rapidly degradable starch, ruminal starch fermentability, and total tract starch digestibility of PS. Grain type interacted with pasteurization such that feeding corn-based diets containing pasteurized PS resulted in periodic reductions in ruminal pH. Feeding management may be more critical when feeding pasteurized PS in beef finishing diets.

[Surgical management of a pleiomorphic adenoma of unusual location]. / Ritka lokalizációjú pleiomorph adenoma operált esete.

The authors describe the occurrence of a parotid pleiomorphic adenoma in an unusual location, beginning in the small salivary gland of the lower lip. The location of the pleiomorph adenoma is rare as mentioned in the bibliography, however, not demonstrated with many actual cases.