Publications by authors named "Cory N Criss"

29 Publications

  • Page 1 of 1

Ultrasound-guided pediatric inguinal hernia repair.

J Pediatr Surg 2021 Mar 11. Epub 2021 Mar 11.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109; Department of Interventional Radiology, Michigan Medicine, Ann Arbor MI USA 48109. Electronic address:

Purpose: Inguinal hernias are amongst the most common surgical conditions in children. Typically, these repairs are performed through an open or laparoscopic approach, using a high ligation of the hernia sac. The use of ultrasound has been described in identifying and evaluating hernia contents in children. Our goal was to determine if ultrasound guidance could be used to perform a high ligation of the hernia sac in pediatric patients.

Methods: Following IRB approval, a retrospective review of all female patients at a single center undergoing ultrasound guided inguinal hernia repair between 2017 and 2018 was performed. Pre-operative characteristics, intra-operative outcomes, and post-operative outcomes were all evaluated. Laparoscopy was used to evaluate the repair and evaluate for a contralateral hernia. Male patients did not undergo ultrasound inguinal hernia repair to avoid damage to the vas deferens and vessels.

Results: A total of 10 patients with 13 hernias total were found during the study period. A total of one patient was converted to a laparoscopic repair. No patients were found to have an inappropriate repair or a missed contralateral hernia, and there were no vascular injuries or injuries to surrounding structures. No patients had a hernia recurrence during the study period.

Conclusion: This study demonstrates the safety and feasibility of ultrasound guided inguinal hernia repairs in female pediatric patients. Further study is needed to compare these repairs to existing techniques, evaluate for recurrences over time, and evaluate if these repairs can be performed without general anesthetic in some patients.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.053DOI Listing
March 2021

Early nephrectomy in neonates with symptomatic autosomal recessive polycystic kidney disease.

J Pediatr Surg 2021 Feb 1;56(2):328-331. Epub 2020 Apr 1.

Division of Pediatric Surgery, Department of Surgery, University of Michigan 1540 E Hospital Dr., Rm 4972, Ann Arbor, MI 48109, United States.

Introduction: Autosomal recessive polycystic kidney disease (ARPKD) is a rare cause of renal failure with a highly variable clinical course. Patients who are symptomatic early in life frequently require early nephrectomy and peritoneal dialysis. In these patients there are little data to guide clinicians on whether to select unilateral nephrectomy or bilateral nephrectomy at the initial operative intervention. We review our experience with this disease process.

Methods: A retrospective review was performed of 11 patients at our institution with ARPKD symptomatic within the first month of life. Charts were reviewed for relevant clinical data, and patients were divided into groups based on undergoing either unilateral or bilateral nephrectomy at their initial intervention. The decision for unilateral versus bilateral nephrectomy was decided by the clinical team without any available guidelines.

Results: Of the 11 patients reviewed, two patients died within the first two weeks from other complications. The remaining 9 all required nephrectomy, with 5 undergoing synchronous bilateral nephrectomy, and 4 undergoing initial unilateral nephrectomy. All four patients required removal of their contralateral kidney, a median of 25.5 days later. There was no difference in mortality, ventilator free days, or time to full feeds between the two groups, although the group undergoing initial unilateral nephrectomy had more TPN days than their counterparts (28 vs 17 days, p = 0.014).

Conclusions: In our cohort, there were few significant differences between the groups based on choice of initial unilateral or bilateral nephrectomy, and all children ultimately required removal of both kidneys. These data suggest that anesthetic exposures and other clinical outcomes might be optimized by initial bilateral nephrectomy.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.03.023DOI Listing
February 2021

Necrotizing enterocolitis in term neonates: A different disease process?

J Pediatr Surg 2019 Jun 1;54(6):1143-1146. Epub 2019 Mar 1.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI.

Introduction: Necrotizing enterocolitis (NEC) has been a long-recognized complication of prematurity, but there is a paucity of studies on term infants. We sought to characterize the clinical presentation and outcomes of full term (FT) infants with NEC and compare these to our experience with preterm (PT) neonates.

Methods: We conducted a chart review of infants admitted to the NICU at University of Michigan with a diagnosis of NEC for over a 10-year period with a Modified Bell stage of 2 or greater. We compared the outcomes and comorbidities of PT against those of FT, defined as gestational age at birth below and above 37 weeks, respectively.

Results: Out of 170 infants, 28(17%) were FT. FT neonates were more likely to have undergone cardiac surgery for a congenital defect, excluding PDA ligation (64% vs. 8%)*. When compared to FT infants, PT infants were more likely to require surgical intervention (18% vs. 59%)*, have Bell stage 3 disease (82% vs. 43%)*, require vasopressor support (21% vs. 42%), and require ventilatory support (43% vs 75%)*. *p<0.01,p<0.05.

Conclusion: FT neonates present with different patterns of disease and have different outcomes, suggesting that this may be a different clinical entity than NEC in preterm infants.

Type Of Study: Retrospective review LEVEL OF EVIDENCE: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.02.046DOI Listing
June 2019

Evaluating a Solely Mechanical Articulating Laparoscopic Device: A Prospective Randomized Crossover Study.

J Laparoendosc Adv Surg Tech A 2019 Apr 20;29(4):542-550. Epub 2019 Feb 20.

3 Department of Surgery, Michigan Medicine, Ann Arbor, Michigan.

Background: The FlexDex (FD) is a solely mechanical articulating device that combines the functionality of robotic surgery with the relative low cost and simplicity of laparoscopy. We sought to evaluate the performance of first-time FD users while performing a simple suture task at locations of varying degrees of difficulty.

Study Design: A prospective, randomized crossover study was performed comparing the FD to standard laparoscopy (SL). Two specific groups were evaluated; Group 1 consisted of complete novices, and Group 2 consisted of surgical trainees. Participants performed a simple suture with both FD and SL locations of varying degrees of difficulty (Easy, Moderate, and Hard). The following outcomes were evaluated: Instrument Function and Ergonomics (Comfort/Ergonomics survey), Task Difficulty (National Aeronautics and Space Administration Task Load Index [NASA-TLX]), Task Performance Quality (Objective Structured Assessment of Technical Skills [OSATS]), and Time (seconds).

Results: Twenty-two participants were enrolled with 12 participants in Group 1 and 10 participants in Group 2. Group 1-FD participants experienced overall less shoulder strain (1.2 ± 0.40 versus 1.9 ± 0.90, P = .01), and Group 2-FD participants experienced less shoulder (2.5 ± 0.66 versus 4.0 ± 0.50, P = .01), back (1.1 ± 0.32 versus 1.9 ± 0.74, P = .01), and forearm strain (1.9 ± 0.88 versus 2.5 ± 1.1, P = .04). Group 1 participants using the FD experienced higher mental demand (73 ± 17 versus 48 ± 27, P < .01) and perceived effort (70 ± 20 versus 54 ± 23, P < .001). Both Group 1 and Group 2 FD participants performed tasks at the Hard location more effectively. Both Group 1 (70 versus 87, P = .21) and Group 2 (53 versus 60, P = .55) performed tasks at the Hard location in similar times, while Group 1 (80 versus 177, P = .03) and Group 2 (33 versus 70, P = .001) performed tasks at the Easy location in shorter times using SL.

Conclusions: This study demonstrates the first assessment of the FD, a mechanically articulating laparoscopic tool. First-time FD users demonstrated improved ergonomics and effectiveness suturing at difficult locations. Future studies will focus on comparison to robotic surgery and translation into clinical applications.
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http://dx.doi.org/10.1089/lap.2018.0539DOI Listing
April 2019

Ultrasound guidance improves safety and efficiency of central line placements.

J Pediatr Surg 2019 Aug 13;54(8):1675-1679. Epub 2018 Sep 13.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI, USA 48109; Division of Interventional Radiology, Department of Radiology, Michigan Medicine, Ann Arbor, USA 48109.

Background: Use of ultrasound-guidance for central venous access in adults is the standard of care. There is, however, less clarity in the role of routine ultrasound use in obtaining venous access in children. We sought to evaluate safety and efficiency of the placement of central lines utilizing an ultrasound-guided approach compared to the traditional, landmark approach in pediatric patients.

Study Design: A single-institution retrospective chart review, using CPT codes, was performed for all tunneled central venous catheters in children between 2005 and 2017 by the same pediatric surgery group. During the study period, a practice change occurred from exclusively landmark-based line placement to ultrasound-guided line placement. Groups were divided into three phases: a traditional/landmark era (Phase 1), transitional period (Phase 2), and the ultrasound era (Phase 3). The primary outcomes analyzed were postoperative chest tube insertions and operative time.

Results: A total of 2010 tunneled central lines were included for analysis: Phase 1 (N = 930), Phase 2 (N = 313) and Phase 3 (N = 767). Venous access for chemotherapy was the most common indication (29%). Phase 1 had a chest tube placement rate of 9.7/1000 procedures, while Phase 2 had a rate of 6.4/1000 procedures, and Phase 3 had no chest tube insertions (p = 0.009). Phase 1 had longer OR times compared to Phase 2 (57 vs. 49, p = 0.0026) and Phase 3 (57 vs. 46 min, p < 0.001).

Conclusions: This study represents the largest analysis of ultrasound-guided access for children. A complete practice transition to the ultrasound-guided approach was feasible within a two-year period. The ultrasound-guided approach had a shorter operative time and less chest tube insertions than the traditional, landmark technique in children. Level III evidence.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.08.039DOI Listing
August 2019

The Impact of Corporate Payments on Robotic Surgery Research: A Systematic Review.

Ann Surg 2019 03;269(3):389-396

Section of Pediatric Surgery, C.S. Mott Children's Hospital, Ann Arbor, MI.

Objective: To quantify the influence of financial conflict of interest (COI) payments on the reporting of clinical results for robotic surgery.

Data Sources And Study Selection: A systematic search (Ovid MEDLINE databases) was conducted (May 2017) to identify randomized controlled trials (RCTs) and observational studies comparing the efficacy of the da Vinci robot on clinical outcomes. Financial COI data for authors (per study) were determined using open payments database.

Main Outcomes And Measures: Primary outcomes assessed were receipt of financial COI payments and overall conclusion reported between robotic versus comparative approach. Quality/risk of bias was assessed using Newcastle-Ottawa Scale (NOS)/Cochrane risk of bias tool. Disclosure discrepancies were also analyzed.

Data Extraction And Synthesis: Study characteristics, surgical subspecialty, methodological assessment, reporting of disclosure statements, and study findings dual abstracted. The association of the amount of financial support received as a predictor of reporting positive findings associated robotic surgery was assessed at various cut-offs of dollar amount received by receiver operating curve (ROC).

Results: Thirty-three studies were included, 9 RCTs and 24 observational studies. There was a median, 111 patients (range 10 to 6420) across studies. A little more than half (17/33) had a conclusion statement reporting positive results in support of robotic surgery, with 48% (16/33) reporting results not in favor [equivocal: 12/33 (36%), negative: 4/33 (12%)]. Nearly all (91%) studies had authors who received financial COI payments, with a median of $3364.46 per study (range $9 to $1,775,378.03). ROC curve demonstrated that studies receiving greater than $9557.31 (cutpoint) were more likely to report positive robotic surgery results (sensitivity: 0.65, specificity: 0.81, area under the curve: 0.73). Studies with financial COI payment greater than this amount were more likely to report beneficial outcomes with robotic surgery [(78.57% vs 31.58%, P = 0.013) with an odds ratio of 2.07 (confidence interval: 0.47-3.67; P = 0.011)]. Overall, studies were high quality/low risk of bias [median NOS: 8 (range 5 to 9)]; Cochrane risk: "low risk" (9/9, 100%)].

Conclusion And Relevance: Financial COI sponsorship appears to be associated with a higher likelihood of studies reporting a benefit of robotic surgery. Our findings suggest a dollar amount where financial payments influence reported clinical results, a concept that challenges the current guidelines, which do not account for the amount of COI funding received.
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http://dx.doi.org/10.1097/SLA.0000000000003000DOI Listing
March 2019

Selective Management of Multiple Bronchopleural Fistulae in a Pediatric Patient on Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach.

J Laparoendosc Adv Surg Tech A 2018 Oct 19;28(10):1271-1274. Epub 2018 Jun 19.

1 Section of Pediatric Surgery, Department of Surgery, Michigan Medicine , Ann Arbor, Michigan.

Introduction: This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral bronchopleural fistulae (BPF) using minimally invasive techniques. In this study, we present a previously healthy 14-year-old male hospitalized with 2009 H1N1 influenza and methicillin-resistant Staphylococcus aureus coinfection complicated by severe acute respiratory distress syndrome and multifocal necrotizing pneumonia, with significant lung tissue damage requiring prolonged extracorporeal membrane oxygenation (ECMO) support.

Methods: The development of multiple BPFs precluded lung recruitment necessary to wean from ECMO. Treatment options were very limited and endobronchial valves were considered. However, localizing single airleaks with a fogarty balloon is normally the technique to determine appropriate location to place the valves. With multiple fistulae, this technique would be ineffective. Therefore, the patient was brought to interventional radiology and bronchography was performed for selective fistula mapping. With this precise localization, the multiple fistulae were ultimately controlled using image-guided embolization and the placement of multiple endobronchial valves. The success of this intervention enabled positive pressure ventilator support and rehabilitation required for weaning from ECMO support.

Conclusion: This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral BPFs using minimally invasive techniques.
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http://dx.doi.org/10.1089/lap.2018.0078DOI Listing
October 2018

Clinic-day surgery for children: a patient and staff perspective.

Pediatr Surg Int 2018 Jul 28;34(7):755-761. Epub 2018 May 28.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI, 48109, USA.

Introduction: For the past 3 years, our institution has implemented a same clinic-day surgery (CDS) program, where common surgical procedures are performed the same day as the initial clinic evaluation. We sought to evaluate the patient and faculty/staff satisfaction following the implementation of this program.

Methods: After IRB approval, patients presenting for the CDS between 2014 and 2017 were retrospectively reviewed. Of these, patient families who received CDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback. In addition, feedback from faculty/staff members directly involved in the program was obtained to determine barriers and satisfaction with the program.

Results: Twenty-nine patients received CDS, with the most commonly performed procedures being inguinal hernia repair (34%) and umbilical hernia repair (24%). Twenty (69%) patients agreed to perform the telephone survey. Parents were overall satisfied with the CDS program, agreeing that the instructions were easy to understand. Overall, 79% of parents indicated that it decreased overall stress/anxiety, with 75% saying it allowed for less time away from work, and 95% agreeing to pursue CDS again if offered. The most common negative feedback was an unspecified operative start time (15%). While faculty/staff members agreed the program was patient-centered, there were concerns over low enrollment and surgeon continuity, because there were different evaluating and operating surgeons.

Conclusion: This study successfully evaluated the satisfaction of patients and faculty/staff members after implementing a clinic-day surgery program. Our results demonstrated improved patient family satisfaction, with families reporting decreased anxiety and less time away from work. Despite this, faculty and staff members reported challenges with enrollment and surgeon continuity.
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http://dx.doi.org/10.1007/s00383-018-4288-3DOI Listing
July 2018

Robotic resection of recurrent pediatric lipoblastoma.

Asian J Endosc Surg 2019 Jan 10;12(1):128-131. Epub 2018 May 10.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA.

This case demonstrates successful resection of a rare, recurrent presacral-pelvic lipoblastoma in a 19-year-old female patient. Because of the anatomical location of the mass and its proximity to vital structures, the robotic approach allowed for both optimal visualization and effective debulking of the mass. Furthermore, with the use of an articulating laparoscopic camera, key visualization of the posterior lateral pelvis was possible. Using a wide breadth of technologies and resources is essential to broadening the surgical armamentarium and achieving resectability in otherwise challenging cases.
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http://dx.doi.org/10.1111/ases.12493DOI Listing
January 2019

Obtaining central access in challenging pediatric patients.

Pediatr Surg Int 2018 May 26;34(5):529-533. Epub 2018 Mar 26.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, 48109, USA.

Purpose: Central catheter placement is one of the most commonly performed procedures by pediatric surgeons. Here, we present a case series of patients where central access was obtained at our institution with the utilization of a novel ultrasound-guided technique. This series represents the first of its kind where the native, parent vessels were inaccessible, resulting in a challenging situation for providers.

Methods: A retrospective chart review was performed in pediatric patients (0-17 years) at a tertiary care institution between July 2012 and November 2017 on all central line procedures where ultrasound was utilized to cannulate the brachiocephalic or superior vena cava in face of proximal occlusion. Our group has previous experience utilizing an image-guided in-plane approach to central line placement in the pediatric population. Demographics, operative characteristics, and postoperative complications were reviewed.

Results: A total of 11 procedures were included in this case series where the BC (N = 9) or SVC (N = 2) were cannulated for access. Internal jugular vein cannulation was attempted on each patient unless preoperative imaging demonstrated occlusion. The median operative time was 43 ± 23 min. Most procedures were performed on the right sided (63%), with catheters ranging from 4.2F single lumen to 14F double lumen. Since being placed, three (27%) catheters have been removed, with one due to non-use, one due to sepsis, and the final one due to malposition.

Conclusion: With the continued need for long-term central access in the pediatric population, distal vein occlusion or inaccessibility can prove challenging when attempting to obtain central access. Here, demonstrated a safe alternative technique that provides an additional option in the pediatric surgeon's armamentarium for patients with difficult central access.
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http://dx.doi.org/10.1007/s00383-018-4251-3DOI Listing
May 2018

Asymptomatic congenital lung malformations: Is nonoperative management a viable alternative?

J Pediatr Surg 2018 Jun 5;53(6):1092-1097. Epub 2018 Mar 5.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI.

Introduction: The purpose of this study was to evaluate clinical outcomes in children with asymptomatic congenital lung malformations (CLM) who were initially managed nonoperatively.

Methods: An IRB-approved retrospective review was performed on all CLMs at a single tertiary care referral center (Jan 2006-Dec 2016, n=140). Asymptomatic cases that did not undergo elective resection were evaluated for subsequent CLM-related complications based on clinical records and a telephone quality of life survey.

Results: Out of 39 (27.9%) who were initially managed nonoperatively, 13 (33%) developed CLM-related symptoms and underwent surgical intervention at a median age of 6.8years (range, 0.7-19.8years). The most common indication for conversion to operative management was pneumonia (78%). Larger lesions, as measured by CT scan, were significantly associated with the need for subsequent surgical intervention (mean maximal diameter, 5.7 vs. 2.9cm; p=0.005). Based on survey data with a median follow up of 3.9years (range, 0.2-13.2years), 17% developed chronic pulmonary symptoms, including cough (11%) and asthma requiring bronchodilators (12%).

Conclusion: Although these data support nonoperative management as a viable alternative to surgical resection, at least one-third of CLM children eventually develop pneumonia or other pulmonary symptoms. Larger lesions are correlated with an increased risk for eventual surgical resection.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.065DOI Listing
June 2018

Outcomes of Adolescent and Young Adults Receiving High Ligation and Mesh Repairs: A 16-Year Experience.

J Laparoendosc Adv Surg Tech A 2018 Feb 20;28(2):223-228. Epub 2017 Dec 20.

1 Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan , Ann Arbor, Michigan.

Introduction: Interestingly, the pediatric and adult surgeons perform vastly different operations in similar patient populations. Little is known about long-term recurrence and quality of life (QOL) in adolescents and young adults undergoing inguinal hernia repair. We evaluated long-term patient-centered outcomes in this population to determine the optimal operative approach.

Methods: The medical records of patients 12-25 years old at the time of a primary inguinal hernia repair at our institution from 2000 to 2016 were retrospectively reviewed. Patients then completed a phone survey of their postoperative courses and QOL. Outcomes of high ligation performed by pediatric surgeons were compared to those of mesh repairs by adult general surgeons. The primary outcome was recurrence. Secondary outcomes included time to recurrence, postoperative complications, and patient-centered outcomes. A Cox regression analysis was used to determine associations for recurrence.

Results: Of 213 patients identified, 143 (67.1%) were repaired by adult surgeons and 70 (32.9%) repaired by pediatric surgeons. Overall recurrence rate for the entire cohort was 5.7% with a median time to recurrence of 3.5 years (interquartile range 120-2155 days). High ligation and mesh repairs had similar rates of recurrence (6.3 versus 5.8, P = .57) and postoperative complications (17% versus 16%, P = .45). 101/213 (47%) patients completed the phone survey. Of those surveyed, 20% reported postoperative pain, 10% had residual numbness and tingling, and 10% of patients complained of intermittent bulging. Overall, a survey comparison showed no differences among subgroups.

Conclusions: In adolescents and young adults, the long-term recurrence rate after inguinal hernia repair is ∼6% with time to recurrence approaching 4 years. Outcomes of high ligation and mesh repair are similar, highlighting the need for individualized approaches for this unique population.
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http://dx.doi.org/10.1089/lap.2017.0511DOI Listing
February 2018

Comparison of early versus delayed strategies for repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation.

J Pediatr Surg 2018 Apr 22;53(4):629-634. Epub 2017 Nov 22.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI. Electronic address:

Purpose: For the last seven years, our institution has repaired infants with CDH that require ECMO early after cannulation. Prior to that, we attempted to decannulate before repair, but repaired on ECMO if we were unable to wean after two weeks. This study compares those strategies.

Methods: From 2002 to 2016, 65 infants with CDH required ECMO. 67.7% were repaired on ECMO, and 27.7% were repaired after decannulation. Data were compared between patients repaired ≤5days after cannulation ("early protocol", n=30) and >5days after cannulation or after de-cannulation ("late protocol", n=35). We used Cox regression to assess differences in outcomes between groups.

Results: Survival for the early and late protocol groups was 43.3% and 68.8%, respectively (p=0.0485). For patients that were successfully decannulated before repair, survival was 94.4%. Moreover, the early repair protocol was associated with prolongation of ECMO (16.8±7.4 vs. 12.6±6.8days, p=0.0216). After multivariate regression, the early repair protocol was an independent predictor of both mortality (HR=3.48, 95% CI=1.28-9.45, p=0.015) and days on ECMO (IRR=1.39, 95% CI=1.07-1.79, p=0.012). All bleeding occurred in patients repaired on ECMO (29.5%, 13/44).

Conclusions: Our data suggest that protocolized CDH repair early after ECMO cannulation may be associated with increased mortality and prolongation of ECMO. However, early repair is not necessarily harmful for those patients who would otherwise be unable to wean from ECMO before repair. Further work is needed to better move towards individualized patient care.

Type Of Study: Treatment Study.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.10.056DOI Listing
April 2018

Outcomes for thoracoscopic versus open repair of small to moderate congenital diaphragmatic hernias.

J Pediatr Surg 2018 Apr 25;53(4):635-639. Epub 2017 Sep 25.

C.S. Mott Children's Hospital 1540 Hospital Dr., Ann Arbor, MI 48108.

Introduction: Indications for thoracoscopic versus open approaches to repair congenital diaphragmatic hernia (CDH) are unclear as the variability in defect size, disease severity and patient characteristics pose a challenge. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.

Methods: All neonates receiving CDH repair of small (type A) and moderate (type B) size defects at an academic children's hospital between 2006 and 2016 were retrospectively reviewed and analyzed. Patients <36weeks gestation, birth weight <1500g, or requiring extracorporeal life support were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. The primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, and mortality.

Results: The 51 patients receiving thoracoscopic (35) and open (16) repairs were similar in patient and hernia characteristics, with median 2-year follow-up for both groups. Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23days, p=0.03), days on ventilator (5 vs. 12, p=0.02), days to start of enteral feeds (5 vs. 10, p<0.001), and days to goal feeds (11 vs. 20, p=0.006). Higher recurrence rates in the thoracoscopic groups (17.1% vs. 6.3%) were not statistically significant (p=0.28). Median time to recurrence was 88days for the open repair and 183days (IQR 165-218) for the thoracoscopic group. There were no mortalities in either group.

Conclusions: In low risk patients born with small to moderate size defects, a thoracoscopic approach was associated with decreased hospital length of stay, mechanical ventilation days, and time to feeding; however, there was a trend towards higher recurrence rates.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.09.010DOI Listing
April 2018

Acute kidney injury in necrotizing enterocolitis predicts mortality.

Pediatr Nephrol 2018 03 5;33(3):503-510. Epub 2017 Oct 5.

Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.

Background: Morbidity and mortality with necrotizing enterocolitis (NEC) remains a significant challenge. Acute kidney injury (AKI) has been shown to worsen survival in critically ill neonates. To our knowledge, this study is the first to evaluate the prevalence of AKI and its impact on outcomes in neonatal NEC.

Methods: We carried out a single-center retrospective chart review of all neonates treated for NEC between 2003 and 2015 (N = 181). AKI is defined as a rise in serum creatinine (SCr) from a previous trough according to neonatal modified KDIGO criteria (stage 1 = SCr rise 0.3 mg/dL or SCr 150 < 200%, stage 2 = SCr rise 200 < 300%, stage 3 = SCr rise ≥300%, SCr 2.5 mg/dL or dialysis). Primary outcome was in-hospital mortality and secondary outcomes were hospital length of stay (LOS) and need for and type of surgery.

Results: Acute kidney injury occurred in 98 neonates (54%), with 39 stage 1 (22%), 31 stage 2 (18%), and 28 stage 3 (16%), including 5 requiring dialysis. Non-AKI and AKI groups were not statistically different in age, weight, Bell's NEC criteria, and medication exposure (vasopressors, vancomycin, gentamicin, or diuretic). Neonates with AKI had higher mortality (44% vs 25.6%, p = 0.008) and a higher chance of death (HR 2.4, CI 1.2-4.8, p = 0.009), but the effect on LOS on survivors did not reach statistical significance (79 days, interquartile range [IQR] 30-104 vs 54 days, IQR 30-92, p = 0.09). Overall, 48 (27.9%) patients required surgical intervention.

Conclusions: This study shows that AKI not only occurs in over half of patients with NEC, but that it is also associated with more than a two-fold higher mortality, highlighting the importance of early recognition and potentially early intervention for AKI.
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http://dx.doi.org/10.1007/s00467-017-3809-yDOI Listing
March 2018

Sponsoring surgeons: An investigation on the influence of the da Vinci robot.

Am J Surg 2018 07 26;216(1):84-87. Epub 2017 Aug 26.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA; Department of General Surgery, Michigan Medicine, Ann Arbor, MI, USA.

Introduction: The integrity of the medical literature about robotic surgery remains unclear despite wide-spread adoption. We sought to determine if payment from Intuitive Surgical Incorporated (ISI) affected quality of the research produced by surgeons.

Methods: Publicly available financial data from the CMS website regarding the top-20 earners from ISI for 2015 was gathered. Studies conducted by these surgeons were identified using PubMed. Inclusion criteria consisted of publications about the da Vinci robot on patient outcomes. The primary outcome of our study was if the study conclusion was positive/equivocal/negative towards the robot. Secondary outcomes included authorship, sponsorship, study controls, and disclosure.

Results: The top earners received $3,296,844 in 2015, with a median of $141,959. Sub-specialties included general surgery (55%), colorectal (20%), thoracic (15%), and obstetrics/gynecology (10%). Of the 37 studies, there was 1 RCT, with observational studies comprising the rest. The majority of the studies (n = 16, 43%) had no control population, with 11 (30%) comparing to same institution/surgeon, Though ISI sponsored only 6 (16%) studies, all with positive conclusions, 27 (73%) studies had positive conclusions for robot use, 9 (24%) equivocal, and only 1 (3%) negative. Overall, 13 earners had lead authorship and 11 senior.

Conclusion: This initial pilot study highlights a potential bias as current literature published by benefactors demonstrates low quality and highly positive conclusions towards approval of the robot. This substantiates the need for a large, systematic review of the potential influence of sponsoring surgeons on medical literature.
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http://dx.doi.org/10.1016/j.amjsurg.2017.08.017DOI Listing
July 2018

A Novel Intuitively Controlled Articulating Instrument for Reoperative Foregut Surgery: A Case Report.

J Laparoendosc Adv Surg Tech A 2017 Sep 20;27(9):983-986. Epub 2017 Jul 20.

Section of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan.

The field of laparoscopic surgery has continued to grow exponentially over the years, prompting new innovative technologies. Despite substantial advancements, standard laparoscopic tools have undergone little design changes and fail to optimize mobility in limited spaces. Advancements in robotics have attempted to address this, allowing for increasing degrees of freedom and articulation of instruments. Even so, this system has proven to be cumbersome with questionable cost-effectiveness. In this study, we present the first use of a solely mechanical intuitively controlled articulating laparoscopic needle driver. The ability to naturally articulate allowed for ease during suturing and knot tying during the critical portions of the operation. The FlexDex surgical instrument demonstrates promise in the field of foregut surgery in addition to other areas of minimally invasive specialties.
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http://dx.doi.org/10.1089/lap.2017.0107DOI Listing
September 2017

Steroid use for refractory hypotension in congenital diaphragmatic hernia.

Pediatr Surg Int 2017 Sep 6;33(9):981-987. Epub 2017 Jul 6.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4211, USA.

Purpose: Guidelines for diagnosis and treatment of adrenal insufficiency (AI) in newborns with congenital diaphragmatic hernia (CDH) are poorly defined.

Methods: From 2002 to 2016, 155 infants were treated for CDH at our institution. Patients with shock refractory to vasopressors (clinically diagnosed AI) were treated with hydrocortisone (HC). When available, random cortisol levels <10 μg/dL were considered low. Outcomes were compared between groups.

Results: Hydrocortisone was used to treat AI in 34% (53/155) of patients. That subset of patients was demonstrably sicker, and mortality was expectedly higher for those treated with HC (37.7 vs. 17.6%, p = 0.0098). Of the subset of patients with random cortisol levels measured before initiation of HC, 67.7% (21/31) had low cortisol levels. No significant differences were seen in survival between the high and low groups, but mortality trended higher in patients with high cortisol levels that received HC. After multivariate analysis, duration of HC stress dose administration was associated with increased risk of mortality (OR 1.11, 95% CI 1.02-1.2, p = 0.021), and total duration of HC treatment was associated with increased risk of sepsis (OR 1.04, 95% CI 1.005-1.075, p = 0.026).

Conclusion: AI is prevalent amongst patients with CDH, but prolonged treatment with HC may increase risk of mortality and sepsis.
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http://dx.doi.org/10.1007/s00383-017-4122-3DOI Listing
September 2017

Ultrasound-Guided Access into the Abdomen in the Setting of Portal Hypertension: A Novel Technique.

J Laparoendosc Adv Surg Tech A 2017 Mar 18;27(3):328-331. Epub 2016 Nov 18.

Department of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan.

As the field of minimally invasive surgery rapidly evolves, there is an opportunity to adopt innovative techniques to accommodate a variety of patient populations. In patients with portal hypertension, a major risk factor upon entry into the abdomen is injury to large, engorged paraumbilical vessels in the anterior abdominal wall. Major blood loss often results from just entering the abdomen. Here, we describe a patient with caput medusae secondary to portal hypertension presenting for laparoscopic repair of a ventral hernia. Using ultrasound guidance, initial port placement into the abdomen was performed safely using needle access, Seldinger technique, and serial dilation for VersaStep™ 5 mm port (Medtronic, Minneapolis, MN) insertion. Overall, this innovative technique is a safe and effective method of entry into the abdomen in a patient with portal hypertension.
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http://dx.doi.org/10.1089/lap.2016.0514DOI Listing
March 2017

Outcomes of Retromuscular Approach for Abdominal Wall Reconstruction in Patients with Inflammatory Bowel Disease.

Am Surg 2016 Jun;82(6):565-70

Department of Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, Ohio, USA.

Ventral hernia repair (VHR) in patients with inflammatory bowel disease (IBD) presents unique surgical challenges including impaired wound healing, concomitant intestinal operations, along with likely future abdominal surgeries. Appropriate techniques and mesh choices in these patients remain under active debate. Herein we report our experience with using a retromuscular approach for major VHR in a consecutive cohort of IBD patients. We identified all patients with IBD undergoing open VHR with retrorectus mesh placement between 2007 and 2013 in our prospectively maintained database. Main outcomes included patient and hernia characteristics, perioperative details, wound complications, and hernia recurrence. A total of 38 patients with IBD met inclusion criteria. Mean hernia defect size was 338 cm(2). Synthetic mesh was used in 16 patients and biologic mesh was used in 22 of patients. A surgical site occurrence (SSO) occurred in 13 (34.2%) patients, 7 (18.4%) of which were surgical site infections (SSIs). There were no instances of postoperative intestinal complications or enterocutaneous fistulae. At the mean follow-up 37 months, there were 3 (9.4%) recurrences. Our retromuscular repairs were associated with a low rate of wound morbidity and no intestinal complications. Furthermore, we report a relatively low rate of recurrences, especially in this series of complex multiply recurrent hernias. Overall, our retromuscular approach seems to be safe and effective in hernia patients with IBD.
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June 2016

Risk factors for wound morbidity after open retromuscular (sublay) hernia repair.

Surgery 2015 Dec 20;158(6):1658-68. Epub 2015 Jun 20.

Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH. Electronic address:

Background: Retrorectus repairs (RR) of abdominal wall hernias are growing in popularity, yet wound morbidity and predictors in this context have been characterized poorly. Models aimed at predicting wound morbidity typically do not control for technique and/or location of mesh. Our aim was to describe wound morbidity and risk factors specifically in the context of RR hernia repair. Our hypothesis was that the incidence of wound morbidity with mesh sublay would be less than predicted by a model that does not control for mesh position.

Methods: Consecutive RR hernia repairs with at least a 90-day follow-up were identified in our prospective database and analyzed. The primary outcome measures were the incidence of surgical-site occurrence (SSO) and surgical-site infection (SSI) via modern, standardized definitions. For predictors of SSO, statistical analysis was performed with univariate analysis, χ(2), and logistic regression as well as multivariate regression.

Results: A total of 306 patients met the inclusion criteria. Eighty-four SSOs identified in 72 (23.5%) patients included 48 (15.7%) SSIs, 14 (4.6%) instances of wound cellulitis, 12 (3.9%) skin dehiscences, 6 (2.0%) seromas, and 4 (1.3%) hematomas but no instances of mesh excision or fistula formation. Treatment entailed antibiotics alone in 30 patients, 14 bedside drainage procedures, 9 radiographically assisted drainage procedures, and 10 returns to the operating room for debridement. After multivariate analysis, diabetes (OR 2.41), hernia width >20 cm (OR 2.49), and use of biologic mesh (OR 2.93) were statistically associated with the development of a SSO (P < .05). Notably, the mere presence of contamination was not independently associated with wound morbidity (OR 1.83, P = .11). SSO and SSI rates anticipated by a recent risk prediction model were 50-80% and 17-83%, respectively, compared with our actual rates of 20-46% and 7-32%.

Conclusion: Based on a large cohort of patients, we identified factors contributing to SSOs specifically for RR hernia repairs. Paradoxically, biologic mesh was an independent predictor of wound morbidity. The development of clinically important mesh complications and rates of wound morbidity less than anticipated by recent predictive models suggest that the retromuscular (sublay) mesh position may be more advantageous.
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http://dx.doi.org/10.1016/j.surg.2015.05.003DOI Listing
December 2015

Transversus abdominis muscle release for repair of complex incisional hernias in kidney transplant recipients.

Am J Surg 2015 Aug 26;210(2):334-9. Epub 2015 Jan 26.

Division of Transplant Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, OH 44106, USA.

Background: Incisional hernias in kidney transplant recipients (KTRs) can be complex because of adjacent bony structures, proximity of the allograft/transplant ureter, and context of immunosuppression. We hypothesized that our novel posterior component separation with transversus abdominis muscle release (TAR) and retromuscular mesh reinforcement offers a safe and durable repair.

Methods: KTRs with incisional hernias repaired using the aforementioned technique were identified within our prospective database (2007 to 2013) and analyzed.

Results: Eleven patients were identified (median age 49 years, body mass index 32). The median hernia size was 30 cm(2) (range 88 to 1,040 cm(2)) and 8 of the 11 patients were recurrent. Intraoperative morbidity consisted of one transplant ureter injury repaired primarily over a stent. Postoperative morbidity consisted of 2 superficial surgical site infections that resolved and 1 readmission for a blood transfusion. There were no instances of mesh infection, explantation, graft loss, or graft dysfunction. With a median follow-up of 12 months (range 3 to 69), 1 (9%) lateral recurrence has been documented.

Conclusions: For complex incisional hernias in KTRs, TAR is associated with low perioperative morbidity and durable repair.
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http://dx.doi.org/10.1016/j.amjsurg.2014.08.043DOI Listing
August 2015

Effects of mesenchymal stem cell and fibroblast coating on immunogenic potential of prosthetic meshes in vitro.

Surg Endosc 2014 Aug 28;28(8):2357-67. Epub 2014 Jun 28.

University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.

Background: The aim of this study was to reveal the effect of fibroblast or mesenchymal stem cell (MSC) coating on the mesh-induced production of IL-1β, IL-6, and VEGF by macrophages.

Methods: Four commonly used surgical meshes were tested in this study, including Parietex, SoftMesh, TIGR, and Strattice. One-square-centimeter pieces of each mesh were placed on top of a monolayer of human fibroblasts or rat MSCs. The coating status was monitored with a light microscope. The human promonocytic cell line U937 was induced to differentiate into macrophages (MΦ). Three weeks later, meshes were transferred to new 24-well plates and cocultured with the MΦs for 72 h. Culture medium was collected and analyzed for IL-1β, IL-6, and VEGF production using standard ELISA essays. Parallel mesh samples were fixed with paraformaldehyde or glutaraldehyde for histology or transmission electronic microscopy (TEM) analyses, respectively.

Results: Uncoated meshes induced increased production of all three cytokines compared with macrophages cultured alone. HF coating further increased the production of both IL-6 and VEGF but reduced IL-1β production. Except for the SoftMesh group, MSC coating significantly blunted release of all cytokines to levels even lower than with MΦs cultured alone. MΦs tended to deteriorate in the presence of MSCs. Both histology and TEM revealed intimate interactions between cell-coated meshes and MΦs.

Conclusions: Cytokine response to fibroblast coating varied, while MSC coating blunted the immunogenic effect of both synthetic and biologic meshes in vitro. Cell coating appears to affect mesh biocompatibility and may become a key process in mesh evolution.
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http://dx.doi.org/10.1007/s00464-014-3470-5DOI Listing
August 2014

Single-center experience with parastomal hernia repair using retromuscular mesh placement.

J Gastrointest Surg 2014 Sep 19;18(9):1673-7. Epub 2014 Jun 19.

Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA.

Background: Parastomal hernias (PHs) are frequent complications of enterostomies. We aimed to evaluate our outcomes of open PH repair with retromuscular mesh reinforcement.

Methods: From 2006 to 2013, 48 parastomal hernias were repaired in 46 consecutive patients undergoing open retromuscular repair. Surgical technique included stoma relocation, retromuscular dissection, posterior component separation, and retromuscular mesh placement. All stomas were prophylactically reinforced with cruciate incisions through mesh. Main outcome measures included demographics, perioperative details, wound complications (classified according to the CDC guidelines), and recurrences.

Results: There were 24 male and 22 female patients with a mean age of 61.8 and body mass index (BMI) of 31.7 kg/m(2). Twenty-four patients had recurrent PH with an average of 3.8 prior repairs. Ostomies included 18 colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-two patients had a concurrent repair of a midline incisional hernia. All patients underwent mesh repair with either biologic (n = 29), lightweight polypropylene (n = 15), or absorbable synthetic mesh (n = 2). There were 15 superficial surgical site infections (SSIs) and 6 deep SSIs. There was one case of an ischemic ostomy requiring surgical revision. No mesh grafts required removal and there were no mesh erosions. At a mean follow-up time of 13 months, five patients (11%) developed a recurrence; three patients required re-repair.

Conclusion: In this largest series of complex open repairs with retromuscular mesh reinforcement and stoma relocation, we demonstrate that this results in an effective repair. This technique should be considered for complex parastomal hernia repair.
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http://dx.doi.org/10.1007/s11605-014-2575-4DOI Listing
September 2014

Functional abdominal wall reconstruction improves core physiology and quality-of-life.

Surgery 2014 Jul;156(1):176-82

University Hospitals Case Medical Center, Case Comprehensive Hernia Center, Cleveland, OH.

Introduction: One of the goals of modern ventral hernia repair (VHR) is restoring the linea alba by returning the rectus muscles to the midline. Although this practice presumably restores native abdominal wall function, improvement of abdominal wall function has never been measured in a scientific fashion. We hypothesized that a dynamometer could be used to demonstrate an improvement in rectus muscle function after open VHR with restoration of the midline, and that this improvement would be associated with a better quality-of-life.

Methods: Thirteen patients agreed to dynamometric analysis before and 6 months after an open posterior component separation (Rives-Stoppa technique complimented with a transversus abdominis muscle release) and mesh sublay. Analysis done using a dynamometer (Biodex 3, Corp, Shirley, NY) included measurement of peak torque (PT; N*m) and PT per bodyweight (BW; %) generated during abdominal flexion in 5 settings: Isokinetic analysis at 45°/s and 60°/s as well as isometric analysis at 0°, -15°, and +15°. Power (W) was calculated during isokinetic settings. Quality-of-life was measured using our validated HerQles survey at the time of each dynamometric analysis.

Results: Thirteen patients (mean age, 54 ± 9 years; mean body mass index, 31 ± 7 kg/m(2)) underwent repair with restoration of the midline using the aforementioned technique. Mean hernia width was 12.5 cm (range, 5-19). Improvements in PT and PT/BW were significant in all 5 settings (P < .05). Improvement in power during isokinetic analyses at 45°/s and 60°/s was also significant (P < .05). All patients reported an improvement in quality-of-life, which was associated positively with each dynamometric parameter.

Conclusion: Restoration of the linea alba during VHR is associated with improved abdominal wall functionality. Analysis of rectus muscle function using a dynamometer showed statistical improvement by isokinetic and isometric measurements, all of which were associated with an improvement in quality-of-life.
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http://dx.doi.org/10.1016/j.surg.2014.04.010DOI Listing
July 2014

Lack of identifiable biologic behavior in a series of porcine mesh explants.

Surgery 2014 Jul 15;156(1):183-9. Epub 2014 Mar 15.

Department of Pathology, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, OH. Electronic address:

Introduction: Biologic matrices used in abdominal wall reconstruction are purported to undergo remodeling into connective tissue resembling native collagen. Key steps in that process include inflammatory response at the mesh/tissue interface, cellular penetration, and neovascularization of the matrix, followed by fibroblast proliferation and collagen deposition. We aimed to examine the concept of biologic mesh remodeling/regeneration in a series of explanted porcine biologic meshes.

Materials And Methods: A cohort of patients who underwent removal of porcine biologic mesh was identified in a prospective database. Mesh/tissue samples were analyzed using standard hematoxylin/eosin and Masson's trichrome staining. Main outcome measures included: inflammatory response at the mesh/tissue interface, foreign body reaction (FBR), cellular penetration, neovascularization, and new collagen deposition. All evaluations were performed by a blinded senior pathologist using established grading scales.

Results: A total of 14 cases with implant time ranging from 4 to 33 months were identified and analyzed. All meshes were placed as intraperitoneal underlay. There were 7 non-cross-linked and 7 cross-linked grafts. Cross-linked grafts were associated with mild FBR and moderate fibrous capsule formation. Similarly, non-cross-linked grafts had mild-to-moderate FBR and encapsulation. Furthermore, non-cross-linked grafts were associated with no neovascularization and minimal peripheral mesh neocellularization. Cross-linked grafts demonstrated neither neovascularization nor neocellularization. Although no grafts were associated with any quantifiable new collagen deposition within the porcine biologic matrix, minimal biodegradation/remodeling was observed at the periphery of the non-cross-linked grafts only.

Conclusion: The biologic behavior of porcine meshes is predicated on their ability to undergo mesh remodeling with resorption and new collagen deposition. In the largest series of human biologic explants, we detected no evidence of xenograft remodeling, especially in the cross-linked group. Although underlay mesh placement and other patient factors may have contributed to our findings, the concept of porcine biologic mesh regeneration does not seem to be prevalent in the clinical setting.
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http://dx.doi.org/10.1016/j.surg.2014.03.011DOI Listing
July 2014

Comparative radiographic analysis of changes in the abdominal wall musculature morphology after open posterior component separation or bridging laparoscopic ventral hernia repair.

J Am Coll Surg 2014 Mar 21;218(3):353-7. Epub 2013 Nov 21.

Case Comprehensive Hernia Center, Department of General Surgery, University Hospitals Case Medical Center, Cleveland, OH. Electronic address:

Background: Large ventral hernias are known to induce atrophic changes to the anterior abdominal wall musculature. We have shown that anterior component separation with external oblique (EO) release, with resultant reconstruction of the midline, results in hypertrophy of the rectus muscle (RM), internal oblique (IO), and transversus abdominis (TA). We aimed to compare and contrast the impact of posterior component separation with transversus abdominis release (TAR) and bridging laparoscopic ventral hernia repair (LVHR) on the muscles of the abdominal wall.

Study Design: Preoperative and at least 6-month postoperative CT scans were analyzed for patients undergoing TAR with midline reconstruction and LVHR without midline reconstruction. A change in the measured area of each abdominal wall muscle was used as the determinant of hypertrophy or atrophy. The areas of the RM, EO, IO, and TA were measured at the L3 to L4 level through the axial plane.

Results: Twenty-five consecutive patients with pre- and postoperative images were analyzed in each group. In the TAR group, the RA, EO, and IO demonstrated significant increases in area. In the LVHR group, no muscles demonstrated any significant changes.

Conclusions: Similar to anterior component separation, hernia repair with TAR results in hypertrophy of the rectus abdominis muscle. In addition, we found that TAR was associated with hypertrophy of both external and internal oblique muscles. Bridging repair during LVHR, on the other hand, did not result in any significant changes in any of the abdominal muscles. Our findings provide clear radiologic evidence that re-creation of the midline by means of the TAR leads to improved anatomy of the abdominal wall, in addition to positive compensatory changes of the lateral abdominal wall musculature.
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http://dx.doi.org/10.1016/j.jamcollsurg.2013.11.014DOI Listing
March 2014

Outcomes of synthetic mesh in contaminated ventral hernia repairs.

J Am Coll Surg 2013 Dec 14;217(6):991-8. Epub 2013 Sep 14.

Hernia Center, Division of Minimal Access and Bariatric Surgery, Greenville Hospital System University Medical Center, Greenville, SC. Electronic address:

Background: Given the questionable long-term durability of biologic meshes, additional prosthetic options for ventral hernia repairs (VHR) in contaminated fields are necessary. Recent evidence suggests improved bacterial resistance of reduced-weight, large-pore synthetics, giving a potential mesh alternative for repair of contaminated hernias. We aimed to evaluate the clinical outcomes of 2 institutions' experience implanting lightweight polypropylene synthetic mesh in clean-contaminated and contaminated fields.

Study Design: Open VHRs performed with polypropylene mesh in the retro-rectus position in clean-contaminated and contaminated fields were evaluated. Primary outcomes parameters included surgical site infection, surgical site occurrence, mesh removal, and hernia recurrence.

Results: One hundred patients (50 male, 50 female) with a mean age of 60 ± 13 years and a mean body mass index (calculated as kg/m(2)) of 32 ± 9.3 met inclusion criteria. There were 42 clean-contaminated and 58 contaminated cases. The incidence of surgical site occurrence was 26.2% in clean-contaminated cases and 34% in contaminated cases. The 30-day surgical site infection rate was 7.1% for clean-contaminated cases and 19.0% for contaminated cases. There were a total of 7 recurrences with a mean follow-up of 10.8 ± 9.9 months (range 1 to 63 months). Mesh removal was required in 4 patients: 2 due to early anastomotic leaks, 1 due to stomal disruption and retraction in a morbidly obese patient, and 1 from a long-term enterocutaneous fistula.

Conclusions: Although perhaps not yet considered standard of care in the United States, we have demonstrated favorable infection, recurrence, and mesh removal rates associated with the use of synthetic mesh in contaminated VHR.
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http://dx.doi.org/10.1016/j.jamcollsurg.2013.07.382DOI Listing
December 2013

Effects of weight reduction surgery on the abdominal wall fascial wound healing process.

J Surg Res 2013 Sep 31;184(1):78-83. Epub 2013 May 31.

Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio 44106, USA.

Background: Bariatric surgery patients enter into a catabolic state postoperatively, which can lead to an aberrant wound healing process. To improve the future treatment of morbidly obese patients, the aim of our study was to understand the link between bariatric surgery and alterations in the wound healing processes.

Methods: A total of 18 morbidly obese Zucker rats were separated into three groups and underwent one of three surgical procedures: Roux-en-Y gastric bypass (RYGB; n = 6); sleeve gastrectomy (GS; n = 6); or midline laparotomy only (n = 6). The rats were weighed on postoperative day 0, 3, 7, and 14. On day 14, the abdominal wall was harvested and underwent histologic and biomechanical evaluation.

Results: A significant difference was found in the weight gain between the laparotomy control group (LC) and bariatric surgical groups at 7 and 14 d. By postoperative day 7, the GS and RYGB rats weighed significantly less than the LC group, losing, on average, 7% and 6% of their initial body weight, respectively, and the LC gained 4% of their weight (P < 0.05). By postoperative day 14, the LC had gained 20% of their original weight, and the two bariatric groups both weighed significantly less (P < 0.05). The breaking strength in the RYGB group (0.42 ± 0.18 N/mm) was significantly lower statistically than LC (0.69 ± 0/19 N/mm). The LC and GS groups (0.62 ± 0.27 N/mm) did not show a significant difference. The results of the histologic analysis showed that the collagen deposition in the wound was significantly lower statistically in the RYGB group compared with the LC group. No histologic difference was noted between the RYGB and GS groups.

Conclusions: Malabsorptive bariatric surgery negatively affects wound healing both histologically and biomechanically compared with nonbariatric models. Although obesity remains a significant factor in the wound healing process, understanding the link between bariatric surgery and alterations in wound healing is imperative before advocating simultaneous repair of ventral hernias during concomitant bariatric surgery.
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http://dx.doi.org/10.1016/j.jss.2013.05.034DOI Listing
September 2013