Publications by authors named "John Scott Roth"

29 Publications

  • Page 1 of 1

Prospective, multicenter study of P4HB (Phasix™) mesh for hernia repair in cohort at risk for complications: 3-Year follow-up.

Ann Med Surg (Lond) 2021 Jan 15;61:1-7. Epub 2020 Dec 15.

Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA.

Background: This study represents a prospective, multicenter, open-label study to assess the safety, performance, and outcomes of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh for primary ventral, primary incisional, or multiply-recurrent hernia in subjects at risk for complications. This study reports 3-year clinical outcomes.

Materials And Methods: P4HB mesh was implanted in 121 patients via retrorectus or onlay technique. Physical exam and/or quality of life surveys were completed at 1, 3, 6,12, 18, 24, and 36 months, with 5-year (60-month) follow-up ongoing.

Results: A total of n = 121 patients were implanted with P4HB mesh (n = 75 (62%) female) with a mean age of 54.7 ± 12.0 years and mean BMI of 32.2 ± 4.5 kg/m (±standard deviation). Comorbidities included: obesity (78.5%), active smokers (23.1%), COPD (28.1%), diabetes mellitus (33.1%), immunosuppression (8.3%), coronary artery disease (21.5%), chronic corticosteroid use (5.0%), hypo-albuminemia (2.5%), advanced age (5.0%), and renal insufficiency (0.8%). Hernias were repaired via retrorectus (n = 45, 37.2% with myofascial release (MR) or n = 43, 35.5% without MR), onlay (n = 8, 6.6% with MR or n = 24, 19.8% without MR), or not reported (n = 1, 0.8%). 82 patients (67.8%) completed 36-month follow-up. 17 patients (17.9% ± 0.4%) experienced hernia recurrence at 3 years, with n = 9 in the retrorectus group and n = 8 in the onlay group. SSI (n = 11) occurred in 9.3% ± 0.03% of patients.

Conclusions: Long-term outcomes following ventral hernia repair with P4HB mesh demonstrate low recurrence rates at 3-year (36-month) postoperative time frame with no patients developing late mesh complications or requiring mesh removal. 5-year (60-month) follow-up is ongoing.
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http://dx.doi.org/10.1016/j.amsu.2020.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750179PMC
January 2021

Ventral hernia patient outcomes postoperatively housed on surgical vs non-surgical units.

Surg Endosc 2020 Jul 27. Epub 2020 Jul 27.

Division of General Surgery, University of Kentucky Department of Surgery, UK HealthCare, 800 Rose Street, Lexington, KY, 40536, USA.

Background: Inpatient hospital units vary in staffing ratios, monitoring, procedural abilities, and experience with unique patients and diagnoses. The purpose of this study is to assess the impact of patient cohorting upon ventral hernia repair outcomes.

Methods: An IRB-approved retrospective review of open ventral hernia repairs between August 2013 and July 2017 was performed. The information of all patient locations during hospitalization, time at location, post-anesthesia care unit duration (PACU), and intensive care unit (ICU) duration was collected. Patient demographics, comorbidities, operative details, cost, and patient outcomes were analyzed. Multivariable analysis of log length of stay (LOS) was assessed with adjustment for clinical and operative factors.

Results: 235 patients underwent open ventral hernia repair. 179 patients were admitted to surgical units, 33 non-surgical units, and 23 stayed on both units. Clinical characteristics including patient age, gender, BMI, and medical comorbidities were similar between patients boarded on surgical versus non-surgical units. Hernia, wound, and operative data were also statistically similar. Patients admitted to non-surgical units for any duration experienced longer hospital stay (4 vs. 6 days, p < 0.001). Patients housed on a non-surgical unit were more likely to transfer rooms than patients on surgical units, 42.9% vs. 10.1% (p < 0.001), respectively. Multivariable analysis of natural log-transformed LOS showed any stay on a non-surgical unit increased LOS by 1.0 days (95% Cl 0.9-1.2 days, p = 0.026). There were no differences in ICU or PACU stay, cost, or postoperative complications in patients housed on surgical versus non-surgical units.

Conclusions: Postoperative surgical patients had an increased length of stay when admitted to non-surgical units. More frequent room transfers occurred in patients admitted to non-surgical units. Evaluation of patient outcomes and LOS in open ventral hernia repair patients based on hospital unit is unique to this study.
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http://dx.doi.org/10.1007/s00464-020-07829-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384391PMC
July 2020

Totally extraperitoneal approach for open complex abdominal wall reconstruction.

Surg Endosc 2021 Jan 6;35(1):159-164. Epub 2020 Feb 6.

Division of General Surgery, Department of Surgery, C 222, Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA.

Background: Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes.

Methods: This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations.

Results: One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively.

Conclusions: TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.
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http://dx.doi.org/10.1007/s00464-020-07374-1DOI Listing
January 2021

Laparoscopic parastomal hernia repair delays recurrence relative to open repair.

Surg Endosc 2021 Jan 6;35(1):415-422. Epub 2020 Feb 6.

Division of General Surgery, Department of Surgery, University of Kentucky, C 222, Chandler Medical Center, 800 Rose Street, Lexington, KY, 40536, USA.

Background: Mesh repair of parastomal hernia is widely accepted as superior to non-mesh repair, yet the most favorable surgical approach is a subject of continued debate. The aim of this study was to compare the clinical outcomes of open versus laparoscopic parastomal hernia repair.

Methods: An IRB-approved retrospective review was conducted comparing laparoscopic (LPHR) or open (OPHR) parastomal hernia repair performed between 2009 and 2017 at our facilities. Patient demographics, preoperative characteristics, operative details, and clinical outcomes were compared by surgical approach. Subgroup analysis was performed by location of mesh placement. Repair longevity was measured using Kaplan-Meier method and Cox proportional hazards regression. Intention to treat analysis was used for this study based on initial approach to the repair.

Results: Sixty-two patients (average age of 61 years) underwent repair (31 LPHR, 31 OPHR). Patient age, gender, BMI, ASA Class, and comorbidity status were similar between OPHR and LPHR. Stoma relocation was more common in OPHR (32% vs 7%, p = .022). Open sublay subgroup was similar to LPHR in terms of wound class and relocation. Open "Other" and Sublay subgroups resulted in more wound complications compared to LPHR (70% and 48% vs 27%, p = .036). Operative duration and hospital length of stay were less with LPHR (p < .001). After adjustment for prior hernia repair, risk of recurrence was higher for OPHR (p = .022) and Open Sublay and Other subgroups compared to LPHR (p = .005 and p = .027, respectively).

Conclusions: Laparoscopic repair of parastomal hernias is associated with shorter operative duration, decreased length of stay, fewer short-term wound complications, and increased longevity of repair compared to open repairs. Direct comparison of repair longevity between LPHR and OPHR with mesh using Kaplan-Meier estimate is unique to this study. Further study is warranted to better understand methods of parastomal hernia repair associated with fewer complications and increased durability.
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http://dx.doi.org/10.1007/s00464-020-07377-yDOI Listing
January 2021

Costs and Complications Associated with Infected Mesh for Ventral Hernia Repair.

Surg Infect (Larchmt) 2020 May 9;21(4):344-349. Epub 2019 Dec 9.

Division of General Surgery, University of Kentucky, Lexington, Kentucky, USA.

Mesh hernia repair is widely accepted because of the associated reduction in hernia recurrence compared with suture-based repair. Despite initiatives to reduce risk, mesh infection and mesh removal are a significant challenge. In an era of healthcare value, it is essential to understand the global cost of care, including the incidence and cost of complications. The purpose of this study was to identify the outcomes and costs of care of patients who required the removal of infected hernia mesh. A review of databases from 2006 through June 2018 identified patients who underwent both ventral hernia repair (VHR) and re-operation for infected mesh removal. Patient demographic and operative details for both procedures, including age, Body Mass Index, mesh type, amount of time between procedures, and information regarding interval procedures were obtained. Clinical outcome measures were the length of the hospital stay, hospital re-admission, incision/non-incision complications, and re-operation. Hospital cost data were obtained from the cost accounting system and were combined with the clinical data for a cost and clinical representation of the cases. Thirty-four patients underwent both VHR and removal of infected mesh material over the 12-year time frame and were included in the analyses; the average age at VHR was 48 years, and 16 patients (47%) were female. Following VHR, 21 patients (62%) experienced incision complications within 90 days post-operatively, the complications ranging from superficial surgical site infection (SSI) to evisceration. A mean of 22.65 months passed between procedures. After mesh removal, 16 patients (47%) experienced further incisional complications; and 22 (65%) patients had at least one re-admission. Eighteen patients (53%) required a minimum of one additional related operative procedure after mesh removal. Median hospital costs nearly doubled (p < 0.001) for the mesh removal ($23,841 [interquartile range {IQR} $13,596-$42,148]) compared with the VHR admission ($13,394 [IQR $8,424-$22,161]) not accounting for re-admission costs. A majority experienced hernia recurrence subsequent to mesh removal. Mesh infection after hernia repair is associated with significant morbidity and costs. Hospital re-admission, re-operations, and recurrences are common among these patients, resulting in greater healthcare resource utilization. Development of strategies to prevent mesh infection, identify patients most likely to experience infectious complications, and define best practices for the care of patients with mesh infection are needed.
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http://dx.doi.org/10.1089/sur.2019.183DOI Listing
May 2020

Clinical and Quality of Life Assessment of Patients Undergoing Laparoscopic Hiatal Hernia Repair.

Am Surg 2019 Nov;85(11):1269-1275

Hiatal hernia repair (HHR) and fundoplication are similarly performed among all hiatal hernia types with similar techniques. This study evaluates the effect of HHR using a standardized technique for cruroplasty with a reinforcing polyglycolic acid and trimethylene carbonate mesh (PGA/TMC) on patient symptoms and outcomes. A retrospective review of patient perioperative characteristics and postoperative outcomes was conducted for cases of laparoscopic hiatal hernia repair (LHHR) using a PGA/TMC mesh performed over 21 months. Gastroesophageal reflux disease symptom questionnaire responses were compared between preoperative and three postoperative time points. Ninety-six patients underwent LHHR with a PGA/TMC mesh. Postoperatively, the number of overall symptoms reported by patients decreased across all postoperative periods ( < 0.001). Patients reported a significant reduction in antacid use long term ( < 0.001). Laryngeal and regurgitation symptoms decreased at all time points ( < 0.05). There was no difference in dysphagia preoperatively and postoperatively at any time point. Individuals undergoing HHR with PGA/TMC mesh experienced improved regurgitation and laryngeal symptoms, and decreased use of antacid medication.
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November 2019

Hernia Repair Strength Enhanced With Antioxidants.

J Surg Res 2020 03 21;247:144-149. Epub 2019 Nov 21.

Division of General Surgery, University of Kentucky, Lexington, Kentucky. Electronic address:

Background: Incisional hernia is one of the most common complications of abdominal surgery, and repairs are associated with significant recurrence rates. Mesh repairs are associated with the best outcomes, but failures are not uncommon. Doxycycline has been demonstrated to enhance mesh hernia repair outcomes with associated increases in collagen deposition and improved tensiometric strength. This study compares the outcomes of incisional hernia repair with doxycycline administration and the antioxidant tempol.

Materials And Methods: Twenty-eight male Sprague Dawley rats underwent a midline hernia creation and an intraabdominal polypropylene mesh repair. The animals were administered saline, doxycycline, tempol, or both, daily for 8 wk. The abdominal wall was harvested at 8 wk and tensiometric strength and biochemical analysis was performed.

Results: The tensiometric strength of the repair was increased in all experimental groups. Collagen type 1 deposition was increased, and collagen type 3 deposition was decreased in each of the experimental groups relative to control. There was no difference in MMP-2 and MMP-9 levels between control and experimental groups.

Conclusions: The hernia repair strength is equally enhanced with the administration of doxycycline or tempol. Dual therapy provided no benefit over treatment with either single agent. All treatment groups had an increase in collagen type 1:3 ratios, but the mechanism is not well understood. The benefits of antioxidant treatment following hernia repair are similar to treatment with doxycycline. Given the high frequency of incisional hernia repair failures, this study has implications for improving outcomes following ventral hernia repair through the use of either doxycycline or antioxidant therapy.
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http://dx.doi.org/10.1016/j.jss.2019.10.031DOI Listing
March 2020

Current strategies for the management of inguinal hernia: What are the available approaches and the key considerations?

Curr Probl Surg 2019 Oct 13;56(10):100645. Epub 2019 Jul 13.

Department of Surgery, University of Kentucky, Lexington, KY.

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http://dx.doi.org/10.1016/j.cpsurg.2019.100645DOI Listing
October 2019

Current strategies for the management of inguinal hernia: What are the available approaches and the key considerations?

Curr Probl Surg 2019 Oct 13;56(10):100646. Epub 2019 Jul 13.

Department of Surgery, University of Kentucky, Lexington, KY.

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http://dx.doi.org/10.1016/j.cpsurg.2019.100646DOI Listing
October 2019

Parastomal Hernia Repair Outcomes: A Nine-Year Experience.

Am Surg 2019 Jul;85(7):738-741

Parastomal hernias (PHs) frequently complicate enterostomy creation. Decision for PH repair (PHR) is driven by patient symptoms due to the frequency of complications and recurrences. The European Hernia Society (EHS) PH classification is based on the PH defect size and the presence/absence of concomitant incisional hernia. The aim of this study was to evaluate PHR outcomes based on EHS classification. An Institutional Review Board-approved retrospective review of a prospective database between 2009 and 2017 was performed. Patient demographics, enterostomy type, EHS classification, operative technique, and clinical outcomes (postoperative complications, 30-day readmission, and PH recurrence) were obtained. Cases were analyzed by EHS classifications I and II (SmallPH) III and IV (LargePH). Sixty-two patients underwent PHR (35: SmallPH, 27: LargePH). Patient groups (SmallPH LargePH) were similar based on American Society of Anesthesiologists Class III and obesity. Hernia recurrence was seen in 26 per cent of repairs with no difference between groups. The median recurrence-free survival was 3.9 years. There was no difference in superficial SSI, deep SSI, nonwound complications, or readmission between SmallPH and LargePH. Both small and large PHs experience similar outcomes after repair. Strategies to improve outcomes should be developed and implemented universally across all EHS PH classes.
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July 2019

Are online surgical discussion boards a safe and useful venue for surgeons to ask for advice? A review of the International Hernia Collaboration Facebook Group.

Surg Endosc 2020 03 9;34(3):1285-1289. Epub 2019 Aug 9.

Department of Surgery, McGovern Medical School at University of Texas Health, 5656 Kelley Street, Houston, TX, 77026, USA.

Background: Social media is a growing medium for disseminating information among surgeons. The International Hernia Collaboration Facebook Group (IHC) is a widely utilized social media platform to share ideas and advice on managing patients with hernia-related diseases. Our objective was to assess the safety and utility of advice provided.

Methods: Overall, 60 consecutive de-identified clinical threads were extracted from the IHC in reverse chronological order. A group of three hernia specialists evaluated all threads for unsafe posts, unhelpful comments, and if an established evidence-based management strategy was provided. Positive and negative controls for safe and unsafe answers were included in seven threads and reviewers were blinded to their presence. Reviewers were free to access all online and professional resources (except the IHC).

Results: There were 598 unique responses (median 10, 1-26 responses per thread) to the 60 clinical threads/scenarios. The review team correctly identified all seven positive and negative controls. Most responses were safe (96.6%) but some were unhelpful (28.4%). For sixteen threads, the reviewers believed there was an established evidence-based answer; however, only six were provided. In addition, 14 responses were considered unsafe, but only four were corrected.

Conclusions: The vast majority of responses were considered helpful; however, evidence-based management is typically not provided and unsafe recommendations often go uncontested. While the IHC allows wide dissemination of hernia-related surgical advice/discussions, surgeons should be cautious when using the IHC for clinical advice. Mechanisms to provide evidence-based management strategies and to identify unsafe advice are needed to improve quality within online forums and to prevent patient harm.
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http://dx.doi.org/10.1007/s00464-019-06895-8DOI Listing
March 2020

Validation and Extension of the Ventral Hernia Repair Cost Prediction Model.

J Surg Res 2019 12 6;244:153-159. Epub 2019 Jul 6.

Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky. Electronic address:

Background: Repair of ventral and incisional hernias remains a costly challenge for health care systems. In a previous study of a single surgeon's elective open ventral hernia repair (VHR) practice, a cost model was developed, which predicted over 70% of hospital cost variation. The purpose of the present study was to evaluate the ventral hernia cost model with multiple surgeons' elective open VHR cases and extending to include nonelective and laparoscopic VHR.

Materials And Methods: With the University of Kentucky Institutional Review Board approval, elective and emergent cases of open and laparoscopic VHR performed by multiple surgeons over 3 y were identified. Perioperative variables were obtained from the local American College of Surgeons National Surgery Quality Improvement Program database and electronic medical record review. Hospital cost data were obtained from the hospital cost accounting system. Forward multivariable regression of log-transformed costs identified independent cost drivers (P for entry < 0.05, and P for exit > 0.10).

Results: Of the 387 VHRs, 74% were open repairs; mean age was 55 y, and 52% of patients were female. For open, elective cases (n = 211; mean cost of $19,145), the previously reported six-factor cost model predicted 45% of the total cost variation. With all VHRs included, additional variables were found to independently drive costs, predicting 59% of the total cost variation from the base cost. The biggest cost drivers were inpatient status (+$1013), use of biologic mesh (+$1131), preoperative systemic inflammatory response syndrome/sepsis (+$894), and preoperative open wound (+$786).

Conclusions: Ventral hernia repair cost variability is predictable. Understanding the independent drivers of cost may be helpful in controlling costs and in negotiating appropriate reimbursement with payers.
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http://dx.doi.org/10.1016/j.jss.2019.06.019DOI Listing
December 2019

Perioperative factors associated with pain following open ventral hernia repair.

Surg Endosc 2019 12 25;33(12):4102-4108. Epub 2019 Feb 25.

Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, C 225, 800 Rose Street, Lexington, KY, 40536, USA.

Background: Effective pain control following open ventral and incisional hernia repair (VHR) impacts all aspects of patient recovery. To reduce opioid use and enhance pain management, multimodal therapy is thought to be beneficial. The purpose of this study was to identify patient characteristics associated with perioperative patient-reported pain scores.

Methods: With IRB approval, surgical databases were searched for cases of open VHR performed over 3 years. Based on a retrospective chart review, modes of pain management and visual analog scale (VAS) pain scores were recorded in 12-h intervals to hospital discharge or to 8 days post-operation. Forward stepwise multivariable regression assessed the independent contribution of the perioperative factors to VAS pain scores.

Results: Included in the analyses were 175 patients that underwent VHR. Average age was 55 years (+/- 12.8), and half were female (50.9%). Factors independently associated with increased preoperative VAS pain scores included preoperative opioid use, preoperative open wound, CDC Wound Class II, and prior hernia repair(s). Patients with epidural for postoperative pain had significantly decreased VAS pain scores across the time continuum. Operative factors significantly associated with increased preoperative VAS pain score included median hernia defect size, concomitantly performed procedure(s), duration of operation, and estimated blood loss. Greater preoperative VAS pain score predicted increased pain at each postoperative time point (all p < .05).

Conclusions: Preoperative pain and opioid use are associated with increased pain postoperatively. Epidural analgesia effectively results in decreased patient-reported pain. Increased operative complexity is associated with increased preoperative pain scores.
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http://dx.doi.org/10.1007/s00464-019-06713-1DOI Listing
December 2019

Long-term efficacy of laparoscopic Nissen versus Toupet fundoplication for the management of types III and IV hiatal hernias.

Surg Endosc 2019 09 26;33(9):2895-2900. Epub 2018 Nov 26.

Division of General Surgery, University of Kentucky, Lexington, KY, USA.

Background: Laparoscopic hiatal hernia repair via Toupet or Nissen fundoplication remains the most commonly performed procedures for management of large hiatal hernia. Few studies have compared the procedures' long-term effectiveness. This study sought to characterize the efficacy of laparoscopic Toupet versus Nissen fundoplication for types III and IV hiatal hernia.

Methods: With IRB approval, a review of all laparoscopic hiatal hernia repairs with mesh reinforcement performed over 7 years at a single center by one surgeon was conducted. Hiatal hernias were classified as type III or IV using operative reports and preoperative imaging. Patients with type I, II, or recurrent hiatal hernia and patients receiving concomitant procedures were excluded. The GERD-Health Related Quality of Life Survey was administered by telephone no earlier than 18 months postoperatively.

Results: A total of 473 patients underwent laparoscopic fundoplication; 179 having type III or IV hiatal hernia met inclusion criteria; 62 underwent Toupet, 117 underwent Nissen fundoplication. Average patient age was 64 years; 63% of patients were female. Cohorts were similar in demographics, comorbidities, and intraoperative factors. Survey was completed by 77 patients (43%): 50 having Nissen and 27 Toupet. Median time of survey completion after surgery was 54 months (Nissen) and 25 months (Toupet). Median survey responses across all items for both groups were 0 (no symptoms) with no significant variation between groups. Of patients that had Nissen, 26% reported current proton-pump inhibitor use versus 31% of Toupet patients (p = 0.486). Patient-reported satisfaction with current condition was similar between groups (67% Toupet, 72% Nissen, p = 0.351).

Conclusions: Patient-reported symptoms and satisfaction did not vary for patients receiving laparoscopic Nissen versus Toupet fundoplication, which may indicate that patients with large type III and IV hiatal hernia undergoing either procedure have similar long-term postoperative symptom control.
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http://dx.doi.org/10.1007/s00464-018-6589-yDOI Listing
September 2019

Abdominal Wall Reconstruction Risk Stratification Tools: A Systematic Review of the Literature.

Plast Reconstr Surg 2018 09;142(3 Suppl):9S-20S

From the Surgery Department, Center for Surgical Trials and Evidence-Based Practice, University of Texas Health Science Center at Houston; and the Surgery Departments of John Hopkins University School of Medicine, New Hanover Regional Medical Center, University of Iowa, University of Nevada School of Medicine, Oregon Health and Science University, University of Kentucky Medical Center; and Ventral Hernia Outcomes Collaborative.

Background: Ventral hernias are a common pathology encountered by surgeons. Multiple risk stratification tools have been developed in attempts to predict a patient's postoperative risk for complication. The aim of this systematic review was to identify published stratification tools, to assess their generalizability, and develop an ensemble risk score model.

Methods: A systematic review of the literature was performed using PubMed and following the PRISMA guidelines. Two independent reviewers identified articles describing hernia stratification tools or validating an established tool. Inclusion criteria included articles that studied ventral hernia risk score models developed through expert consensus or from data of at least 500 subjects, performed a multivariable analysis of at least 500 patients, or assessed a previously reported model. Studies were grouped by primary outcome, and the odds ratios for correlated variables were compiled. Outcomes described in 4 or more articles were then stacked to generate a cumulative risk score model for patients undergoing abdominal wall repair.

Results: A total of 20 articles were found to meet our inclusion criteria and used to develop our ensemble model. Surgical-site infection, surgical-site occurrence, and hernia recurrence were the 3 primary outcomes used to calculate our stacked cumulative risk stratification score.

Conclusions: There are multiple risk score tools published; however, all have their strengths and limitations. For this reason, we created a composite score model with data from major articles to predict a patient's risk for postoperative complications. This model aims to ease the shared-decision making process for patients, surgeons, and institutions.
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http://dx.doi.org/10.1097/PRS.0000000000004833DOI Listing
September 2018

Risk-Assessment Score and Patient Optimization as Cost Predictors for Ventral Hernia Repair.

J Am Coll Surg 2018 04 4;226(4):540-546. Epub 2018 Jan 4.

Department of Surgery, University of Kentucky, Lexington, KY; Division of General Surgery, University of Kentucky, Lexington, KY. Electronic address:

Background: Ventral hernia repair (VHR) is associated with complications that significantly increase healthcare costs. This study explores the associations between hospital costs for VHR and surgical complication risk-assessment scores, need for cardiac or pulmonary evaluation, and smoking or obesity counseling.

Study Design: An IRB-approved retrospective study of patients having undergone open VHR over 3 years was performed. Ventral Hernia Risk Score (VHRS) for surgical site occurrence and surgical site infection, and the Ventral Hernia Working Group grade were calculated for each case. Also recorded were preoperative cardiology or pulmonary evaluations, smoking cessation and weight reduction counseling, and patient goal achievement. Hospital costs were obtained from the cost accounting system for the VHR hospitalization stratified by major clinical cost drivers. Univariate regression analyses were used to compare the predictive power of the risk scores. Multivariable analysis was performed to develop a cost prediction model.

Results: The mean cost of index VHR hospitalization was $20,700. Total and operating room costs correlated with increasing CDC wound class, VHRS surgical site infection score, VHRS surgical site occurrence score, American Society of Anesthesiologists class, and Ventral Hernia Working Group (all p < 0.01). The VHRS surgical site infection scores correlated negatively with contribution margin (-280; p < 0.01). Multivariable predictors of total hospital costs for the index hospitalization included wound class, hernia defect size, age, American Society of Anesthesiologists class 3 or 4, use of biologic mesh, and 2+ mesh pieces; explaining 73% of the variance in costs (p < 0.001). Weight optimization significantly reduced direct and operating room costs (p < 0.05). Cardiac evaluation was associated with increased costs.

Conclusions: Ventral hernia repair hospital costs are more accurately predicted by CDC wound class than VHR risk scores. A straightforward 6-factor model predicted most cost variation for VHR.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.12.022DOI Listing
April 2018

Early outcomes of an enhanced recovery protocol for open repair of ventral hernia.

Surg Endosc 2018 06 21;32(6):2914-2922. Epub 2017 Dec 21.

Division of General Surgery, University of Kentucky, Lexington, KY, USA.

Background: Enhanced recovery after surgery (ERAS) protocols are evidence-based quality improvement pathways reported to be associated with improved patient outcomes. The purpose of this study was to compare short-term outcomes for open ventral hernia repair (VHR) before and after implementation of an ERAS protocol.

Methods: After obtaining IRB approval, surgical databases were searched for VHR cases for two years prior and eleven months after protocol implementation for retrospective review. Groups were compared on perioperative characteristics and clinical outcomes using chi-square, Fisher's exact, or Mann-Whitney U test, as appropriate.

Results: One hundred and seventy-one patients underwent VHR (46 patients with ERAS protocol in place and 125 historic controls). Age, gender, ASA Class, comorbidities, and smoking status were similar between the two groups. Body mass index was lower among ERAS patients (p = .038). ERAS patients had earlier return of bowel function (median 3 vs. 4 days) (p = .003) and decreased incidence of superficial surgical site infection (SSI) (7 vs. 25%) (p = .008) than controls.

Conclusion: An ERAS protocol for VHR demonstrated improved patient outcomes. A system-wide culture focused on enhanced recovery is needed to ensure improved patient outcomes.
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http://dx.doi.org/10.1007/s00464-017-6004-0DOI Listing
June 2018

Prospective evaluation of poly-4-hydroxybutyrate mesh in CDC class I/high-risk ventral and incisional hernia repair: 18-month follow-up.

Surg Endosc 2018 04 23;32(4):1929-1936. Epub 2017 Oct 23.

Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA.

Background: Long-term resorbable mesh represents a promising technology for complex ventral and incisional hernia repair (VIHR). Preclinical studies indicate that poly-4-hydroxybutyrate (P4HB) resorbable mesh supports strength restoration of the abdominal wall. This study evaluated outcomes of high-risk subjects undergoing VIHR with P4HB mesh.

Methods: This was a prospective, multi-institutional study of subjects undergoing retrorectus or onlay VIHR. Inclusion criteria were CDC Class I, defect 10-350 cm, ≤ 3 prior repairs, and ≥ 1 high-risk criteria (obesity (BMI: 30-40 kg/m), active smoker, COPD, diabetes, immunosuppression, coronary artery disease, chronic corticosteroid use, hypoalbuminemia, advanced age, and renal insufficiency). Physical exam and/or quality of life surveys were performed at regular intervals through 18 months (to date) with longer-term, 36-month follow-up ongoing.

Results: One hundred and twenty-one subjects (46M, 75F) with an age of 54.7 ± 12.0 years and BMI of 32.2 ± 4.5 kg/m (mean ± SD), underwent VIHR. Comorbidities included the following: obesity (n = 95, 78.5%), hypertension (n = 72, 59.5%), cardiovascular disease (n = 42, 34.7%), diabetes (n = 40, 33.1%), COPD (n = 34, 28.1%), malignancy (n = 30, 24.8%), active smoker (n = 28, 23.1%), immunosuppression (n = 10, 8.3%), chronic corticosteroid use (n = 6, 5.0%), advanced age (n = 6, 5.0%), hypoalbuminemia (n = 3, 2.5%), and renal insufficiency (n = 1, 0.8%). Hernia types included the following: primary ventral (n = 17, 14%), primary incisional (n = 54, 45%), recurrent ventral (n = 15, 12%), and recurrent incisional hernia (n = 35, 29%). Defect and mesh size were 115.7 ± 80.6 and 580.9 ± 216.1 cm (mean ± SD), respectively. Repair types included the following: retrorectus (n = 43, 36%), retrorectus with additional myofascial release (n = 45, 37%), onlay (n = 24, 20%), and onlay with additional myofascial release (n = 8, 7%). 95 (79%) subjects completed 18-month follow-up to date. Postoperative wound infection, seroma requiring intervention, and hernia recurrence occurred in 11 (9%), 7 (6%), and 11 (9%) subjects, respectively.

Conclusions: High-risk VIHR with P4HB mesh demonstrated positive outcomes and low incidence of hernia recurrence at 18 months. Longer-term 36-month follow-up is ongoing.
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http://dx.doi.org/10.1007/s00464-017-5886-1DOI Listing
April 2018

Concomitant open ventral hernia repair: what is the financial impact of performing open ventral hernia with other abdominal procedures concomitantly?

Surg Endosc 2018 04 19;32(4):1915-1922. Epub 2017 Oct 19.

University of Kentucky Department of Surgery, Lexington, KY, USA.

Background: Open ventral hernia repair (VHR) is often performed in conjunction with other abdominal procedures. Clinical outcomes and financial implications of VHR are becoming better understood; however, financial implications of concomitant VHR during other abdominal procedures are unknown. This study aimed to evaluate the financial implications of adding VHR to open abdominal procedures.

Methods: This IRB-approved study retrospectively reviewed hospital costs to 180-day post-discharge of standalone VHRs, isolated open abdominal surgeries (bowel resection or stoma closure, removal of infected mesh, hysterectomy or oophorectomy, panniculectomy or abdominoplasty, open appendectomy or cholecystectomy), performed at our institution from October 1, 2011 to September 30, 2014. The perioperative risk data were obtained from the local National Surgery Quality Improvement Program (NSQIP) database, and resource utilization data were obtained from the hospital cost accounting system.

Results: 345 VHRs, 1389 open abdominal procedures as described, and 104 concomitant open abdominal and VHR cases were analyzed. The VHR-only group had lower ASA Class, shorter operative duration, and a higher percentage of hernias repaired via separation of components than the concomitant group (p < 0.001). The median hospital cost for VHR-alone was $12,900 (IQR: $9500-$20,700). There were significant increases to in-hospital costs when VHR was combined with removing an infected mesh (63%) or with bowel resections or stoma closures (0.7%). The addition of VHR did not cause a significant change in 180-day post-discharge costs for any of the procedures.

Conclusions: This study noted decreased costs when combining VHR with panniculectomy or abdominoplasty and hysterectomy or oophorectomy. For removal of infected mesh and bowel resection or stoma closure, waiting, when feasible, is recommended. Given the impending changes in financial reimbursements in healthcare in the United States, it is prudent that future studies evaluate further the clinical and fiscal benefit of concomitant procedures.
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http://dx.doi.org/10.1007/s00464-017-5884-3DOI Listing
April 2018

Predictors of outpatient resource utilization following ventral and incisional hernia repair.

Surg Endosc 2018 04 15;32(4):1695-1700. Epub 2017 Sep 15.

Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, C 225, Chandler Medical Center, 800 Rose Street, Lexington, KY, 40536, USA.

Introduction: Little is known about the predictors of increased ambulatory costs following open ventral and incisional hernia repair (VIHR); however, postoperative complications would be expected to be associated with an increased burden on outpatient resources. The purpose of this study is to evaluate the impact of perioperative factors on outpatient resource utilization following VIHR.

Methods: With IRB approval, the surgery scheduling system was queried to identify all cases of VIHR done at our institution over 3 years. Cases with other procedures done at time of VIHR were excluded. National Surgical Quality Improvement Program clinical data, physician billing data which included market and payor across cases, and medical record review data were combined and evaluated in order to quantify care and predictors of usage during the 6 months postoperatively.

Results: Data were analyzed for 308 patients. Median patient age was 52 years (SD = 13.3), and over half were female. The number of outpatient visits to the surgical office varied from 0 to 18 [median = 2; interquartile range (IQR) = 1-3]. CDC Wound Class >1 was associated with increase of mean 1.4 visits (IQR: 0.5-2.3); p = 0.003. Component separation, longer duration of operation, and increased mesh size were also predictive of increased number of office visits (p < 0.01). Postoperative infected seroma/seroma requiring drainage added a mean 2.3 visits (IQR: 1.3-3.3), (p < 0.001); and deep wound infection added a mean 3.9 visits (IQR: 1.9-5.9) (p < 0.001).

Conclusions: Postoperative complications confer a significant burden for patients and to the outpatient surgical office. In an era in which improved quality and cost-efficiency has become imperative, measures to decrease risk of postoperative complications particularly for more complex VIHR would be expected to decrease resource utilization and increase value of care.
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http://dx.doi.org/10.1007/s00464-017-5849-6DOI Listing
April 2018

Ventral hernia repair with poly-4-hydroxybutyrate mesh.

Surg Endosc 2018 04 15;32(4):1689-1694. Epub 2017 Sep 15.

Division of General Surgery, Department of Surgery, C 225, Chandler Medical Center, University of Kentucky College of Medicine, 800 Rose Street, Lexington, KY, 40536, USA.

Background: Biomaterial research has made available a biologically derived fully resorbable poly-4-hydroxybutyrate (P4HB) mesh for use in ventral and incisional hernia repair (VIHR). This study evaluates outcomes of patients undergoing VIHR with P4HB mesh.

Methods: An IRB-approved prospective pilot study was conducted to assess clinical and quality of life (QOL) outcomes for patients undergoing VIHR with P4HB mesh. Perioperative characteristics were defined. Clinical outcomes, employment status, QOL using 12-item short form survey (SF-12), and pain assessments were followed for 24 months postoperatively.

Results: 31 patients underwent VIHR with bioresorbable mesh via a Rives-Stoppa approach with retrorectus mesh placement. The median patient age was 52 years, median body mass index was 33 kg/m, and just over half of the patients were female. Surgical site occurrences occurred in 19% of patients, most of which were seroma. Hernia recurrence rate was 0% (median follow-up = 414 days). Patients had significantly improved QOL at 24 months compared to baseline for SF-12 physical component summary and role emotional (p < 0.05).

Conclusions: Ventral hernia repair with P4HB bioresorbable mesh results in favorable outcomes. Early hernia recurrence was not identified among the patient cohort. Quality of life improvements were noted at 24 months versus baseline for this cohort of patients with bioresorbable mesh. Use of P4HB mesh for ventral hernia repair was found to be feasible in this patient population. (ClinicalTrials.gov Identifier: NCT01863030).
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http://dx.doi.org/10.1007/s00464-017-5848-7DOI Listing
April 2018

Complex Ventral Hernia Repair with Acellular Dermal Matrices: Clinical and Quality of Life Outcomes.

Am Surg 2017 Feb;83(2):141-147

Acellular dermal matrices (ADMs) are used in conjunction with complex hernia repair, but their efficacy is often debated. This study assesses clinical and quality of life (QOL) outcomes in multiply comorbid patients undergoing complex ventral hernia repair using ADMs. After obtaining institutional review board approval, a prospective study was conducted evaluating patients undergoing complex ventral incisional hernia repair with abdominal wall reconstruction (AWR) using either human (Flex HD) or porcine ADM (Strattice). Patient accrual occurred over three years. Demographics, comorbid conditions, and operative details were recorded. Postoperative two-week, six-week, six-month, and one-year follow-up occurred. Primary outcomes measures include wound occurrence, QOL parameters using the Short Form-12 health survey, and hernia recurrence. Groups were compared using chi-squared, Fisher's exact, Mann-Whitney U, or t tests as appropriate. Significance was set at P < 0.05. Thirty-five patients underwent hernia repair using ADM: mean age = 58 years, mean body mass index = 34 kg/m2, >50 per cent Centers for Disease Control and Prevention Wound Class II and above, >50 per cent recurrent hernia repair, and 25 per cent current or previous mesh infection. Twenty patients (57%) experienced surgical site occurrences, 15 (43%) wound infections, and 5 (14%) recurrences with a median follow-up of one year. All Short Form-12 QOL indicators improved at 12 months compared with baseline (NS). Outcomes were similar between mesh types. In conclusion, abdominal wall reconstruction for complex hernias using biologic materials is safe but has significant morbidity. Wound complications occur in over half of all patients and are not impacted by ADM type. There is no decrement in QOL one year after hernia repair despite associated morbidity.
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February 2017

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

Ann Surg 2017 01;265(1):80-89

*University of Texas Health Science Center at Houston, Houston, TX †Veterans Affairs Boston Healthcare System, Boston University and Harvard Medical School, Boston, MA ‡Baylor College of Medicine, Texas Medical Center, Houston, TX §Center for Minimally Invasive and Robotic Surgery, Peoria, AZ ¶University of Iowa, Iowa City, IA ||Medical College of Wisconsin, Milwaukee, WI **University of Wisconsin, Madison, WI ††Oregon Health and Science University, Portland, OR ‡‡West Virginia University, Morgantown, WV §§University of Kentucky, Lexington, KY ¶¶Indiana University Health, Indianapolis, IN ||||Beverly Hills Hernia Center, Beverly Hills, CA ***University of Nevada School of Medicine, Las Vegas, NV †††George Washington University, Washington, DC.

Objective: To achieve consensus on the best practices in the management of ventral hernias (VH).

Background: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence.

Methods: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy.

Results: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients.

Conclusions: Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.
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http://dx.doi.org/10.1097/SLA.0000000000001701DOI Listing
January 2017

Hiatal Hernia Cruroplasty with a Running Barbed Suture Compared to Interrupted Suture Repair.

Am Surg 2016 09;82(9):e271-4

Department of Surgery, University of Kentucky, Lexington, Kentucky, USA.

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September 2016

Do risk calculators accurately predict surgical site occurrences?

J Surg Res 2016 06 26;203(1):56-63. Epub 2016 Mar 26.

Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas.

Introduction: Current risk assessment models for surgical site occurrence (SSO) and surgical site infection (SSI) after open ventral hernia repair (VHR) have limited external validation. Our aim was to determine (1) whether existing models stratify patients into groups by risk and (2) which model best predicts the rate of SSO and SSI.

Methods: Patients who underwent open VHR and were followed for at least 1 mo were included. Using two data sets-a retrospective multicenter database (Ventral Hernia Outcomes Collaborative) and a single-center prospective database (Prospective)-each patient was assigned a predicted risk with each of the following models: Ventral Hernia Risk Score (VHRS), Ventral Hernia Working Group (VHWG), Centers for Disease Control and Prevention Wound Class, and Hernia Wound Risk Assessment Tool (HW-RAT). Patients in the Prospective database were also assigned a predicted risk from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Areas under the receiver operating characteristic curve (area under the curve [AUC]) were compared to assess the predictive accuracy of the models for SSO and SSI. Pearson's chi-square was used to determine which models were able to risk-stratify patients into groups with significantly differing rates of actual SSO and SSI.

Results: The Ventral Hernia Outcomes Collaborative database (n = 795) had an overall SSO and SSI rate of 23% and 17%, respectively. The AUCs were low for SSO (0.56, 0.54, 0.52, and 0.60) and SSI (0.55, 0.53, 0.50, and 0.58). The VHRS (P = 0.01) and HW-RAT (P < 0.01) significantly stratified patients into tiers for SSO, whereas the VHWG (P < 0.05) and HW-RAT (P < 0.05) stratified for SSI. In the Prospective database (n = 88), 14% and 8% developed an SSO and SSI, respectively. The AUCs were low for SSO (0.63, 0.54, 0.50, 0.57, and 0.69) and modest for SSI (0.81, 0.64, 0.55, 0.62, and 0.73). The ACS-NSQIP (P < 0.01) stratified for SSO, whereas the VHRS (P < 0.01) and ACS-NSQIP (P < 0.05) stratified for SSI. In both databases, VHRS, VHWG, and Centers for Disease Control and Prevention overestimated risk of SSO and SSI, whereas HW-RAT and ACS-NSQIP underestimated risk for all groups.

Conclusions: All five existing predictive models have limited ability to risk-stratify patients and accurately assess risk of SSO. However, both the VHRS and ACS-NSQIP demonstrate modest success in identifying patients at risk for SSI. Continued model refinement is needed to improve the two highest performing models (VHRS and ACS-NSQIP) along with investigation to determine whether modifications to perioperative management based on risk stratification can improve outcomes.
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http://dx.doi.org/10.1016/j.jss.2016.03.040DOI Listing
June 2016

Laparoscopic ventral hernia repair with primary fascial closure versus bridged repair: a risk-adjusted comparative study.

Surg Endosc 2016 08 17;30(8):3231-8. Epub 2015 Nov 17.

Department of Surgery, University of Kentucky, C-225 Chandler Medical Center, 800 Rose Street, Lexington, KY, 40536, USA.

Background: Laparoscopy, specifically the bridged mesh technique, is a popular means used for ventral hernia repair. While laparoscopy has decreased the incidence of surgical site infection (SSI), hernia recurrence rates remain unchanged. Some surgeons advocate laparoscopic primary fascial closure (PFC) with placement of intraperitoneal mesh to decrease recurrence rates. We hypothesize that in patients undergoing laparoscopic ventral hernia repair (LVHR), PFC compared to a bridged mesh repair decreases hernia recurrence rates.

Methods: A multicenter, retrospective database of all ventral hernia repairs performed from 2010-2012 was accessed. Patients who underwent LVHR with mesh were reviewed. Patients who had PFC were compared to bridged repair. Primary outcome was hernia recurrence determined by clinical examination or CT scan. Secondary outcomes included SSI and seroma formation.

Results: A total of 1594 patients were identified. Following exclusion, a total of 196 patients were left who underwent LVHR with a mean follow-up period of 17.5 months. Ninety-seven patients underwent PFC, while 99 underwent bridged repairs. Initial comparisons between both groups was negative for any significant statistical difference in terms of recurrence, seroma formation, SSI, deep/organ space SSI, reoperation, and readmission. The same initial findings held true during subgroup analysis. Propensity score analysis was then performed for recurrence, seroma, and SSI controlling for age, gender, immune status, ASA class, BMI, smoking status, and acute repair. No statistically significant differences were identified in either group.

Conclusion: Primary fascial closure during laparoscopic hernia repairs did not result in reduced recurrence, seroma, and SSI as compared to bridge repairs in a retrospective, multi-institutional study. However, additional research is needed to further evaluate benefits to the patient in terms of pain, function, cosmesis, and overall satisfaction. Randomized, blinded, control trials should focus on these parameters in future investigations.
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http://dx.doi.org/10.1007/s00464-015-4644-5DOI Listing
August 2016

Laparoscopic parastomal hernia repair: No different than a laparoscopic ventral hernia repair?

Surg Endosc 2016 Apr 7;30(4):1542-6. Epub 2015 Jul 7.

Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, 800 Rose Street, UKMC C-222, Lexington, KY, 40536-0298, USA.

Background: Parastomal hernia (PH) is a common complication when a stoma is used. The high incidence (35-50%) and patient longevity have created a situation where patients are being referred for consideration of repair with more frequency. Due to the presence of an ostomy and the increased bacterial contamination of the area, the insertion of a prosthetic material is concerning for complications. Laparoscopic repair of parastomal hernias utilizing a modified Sugarbaker technique has been demonstrated to have excellent outcomes. The purpose of this study is to demonstrate that laparoscopic PH repair has outcomes similar to laparoscopic ventral hernia (LVH) repair without the presence of a stoma.

Methods: After obtaining institutional review board approval, patients with parastomal hernia who underwent laparoscopic repair using Sugarbaker technique between 2009 and 2012 were compared to patients with ventral hernias who underwent LVH repair in a retrospective review, with a match of 1:3. Data collected included demographics, comorbidities, operative time, defect size, and mesh size. Outcomes and complications were compared between the two groups.

Results: Twenty patients underwent Sugarbaker repair, and these cases were compared to 60 patients with ventral hernia that received LVH repair. There was no statistically significant difference in age, BMI, smoking status, ASA score, defect size, or mesh size between groups. Operative time was significantly longer in the PH group: 172 ± 35 versus the LVH group: 94 ± 32 min (p < 0.1). Length of stay was longer, 3 days (3-5.5) for PH versus 1 day (1-2.8) for LVH, p < 0.1. The two groups did not differ in terms of wound complications or recurrence, with a median follow-up of 37 days (IQ range 27-518).

Conclusion: The Sugarbaker technique is as safe as LVH repair with no more complications given the presence of a stoma.
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http://dx.doi.org/10.1007/s00464-015-4370-zDOI Listing
April 2016

Implementation of a low-cost laparoscopic skills curriculum in a third-world setting.

J Surg Educ 2014 Nov-Dec;71(6):860-4. Epub 2014 Jun 13.

Department of General Surgery, University of Kentucky, Lexington, Kentucky.

Background: Training outside the operating room has become a mainstay of surgical education. Laparoscopic training often takes place in a simulation setting. Advanced laparoscopic procedures are now commonplace, even in third-world countries with minimal hospital resources. We sought to implement a low-cost laparoscopic skills curriculum in a general surgery residency program in East Africa.

Study Design: The laparoscopic skills curriculum created and validated at the University of Kentucky was presented to the 10 general surgery residents at Tenwek Hospital. The curriculum and all materials were purchased for approximately $50 (USD). The residents in Kenya had access to laparoscopic trainer boxes and personal laptops to perform the simulations. Residents were timed on their performance at the initiation of the project and after 3 weeks of practice.

Results: Residents were tested on 3 separate tasks (cannulation drill, peg board, and rope pass). At the initiation of the project, residents were unable to complete the 3 tasks chosen for timing without a critical error (i.e., dropping a peg out of view). After 3 weeks of independent practice, residents were able to successfully complete the tasks, nearing the time limits established in the curriculum manual. Additional practice and testing sessions are scheduled for the remainder of the year.

Conclusions: Implementation of a low-cost laparoscopic skills curriculum in a third-world setting is feasible. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be a vital aspect of the growing surgical residency training in third-world settings.
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http://dx.doi.org/10.1016/j.jsurg.2014.05.004DOI Listing
August 2015

Gluteal compartment syndrome and sciatica after bone marrow biopsy: a case report and review of the literature.

Am Surg 2002 Sep;68(9):791-4

Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, North Carolina 27858, USA.

The gluteal region is not commonly thought of as a compartment, yet nondistensible osseofascial boundaries do exist. As with any case of compartment syndrome expedient therapeutic measures are critical to salvaging neuromuscular function. The gluteal compartment is unique, however, because of its tremendous muscle mass and great potential for producing devastating systemic sequelae. Gluteal compartment syndrome is most commonly associated with unconscious patients who are recumbent for prolonged periods, but trauma, spontaneous bleeding, and overexertion can also cause it. We present a case report of gluteal compartment syndrome after bone marrow biopsy of the iliac crest. Recognizing gluteal compartment syndrome as an entity and maintaining a high index of suspicion for its development especially in unconscious patients can avert disaster regardless of etiology.
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September 2002