Publications by authors named "S B Orenstein"

174 Publications

Enhanced Recovery Pathway for Complex Abdominal Wall Reconstruction.

Plast Reconstr Surg 2018 09;142(3 Suppl):133S-141S

From the Oregon Health & Science University.

Ventral hernia repair with abdominal wall reconstruction can be a challenging endeavor, as patients commonly present not only with complex and recurrent hernias but also often with comorbidities that increase the risk of postoperative complications including wound morbidity and hernia recurrence, among other risks. By optimizing patient comorbidities in the preoperative setting and managing postoperative care in a regimented fashion, enhanced recovery after surgery pathways allow for a systematic approach to reduce complications and speed up recovery following ventral hernia repair.
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http://dx.doi.org/10.1097/PRS.0000000000004869DOI Listing
September 2018

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

Sarcopenia and outcomes in ventral hernia repair: a preliminary review.

Hernia 2018 08 11;22(4):645-652. Epub 2018 May 11.

Division of GI and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.

Purpose: Sarcopenia, or loss of muscle mass, is associated with increased morbidity and mortality in oncologic resections and several other major surgeries. Complex ventral hernia repairs (VHRs) and abdominal wall reconstruction are often performed in patients at high risk for morbidity and recurrence, though limited data exist on outcomes related to sarcopenia. We aimed to determine if sarcopenia is associated with worse outcomes in patients undergoing VHR.

Methods: We reviewed patients undergoing VHRs from 2014 to 2015. Preoperative CT images were analyzed for cross-sectional muscle mass. Patients with and without sarcopenia underwent statistical analysis to evaluate differences in perioperative morbidity and hernia recurrence. Muscle indices were analyzed independently for outcomes.

Results: 135 patients underwent VHR with/without fistula takedown, staged repairs or other concomitant procedures. 27% had sarcopenia (age 34-84, BMI 27-33, 62% male). Postoperative complications occurred in 43% of sarcopenic patients and 47% of non-sarcopenic patients (p = 0.70). Surgical site infections (SSI) were seen in 16% of sarcopenic patients compared to 29% without sarcopenia (p = 0.14). There was no difference in hernia recurrence between groups (p = 0.90). However, after adjusting for diabetes and BMI, a 10 cm/m decrease in muscle index had 1.44 OR of postoperative complications (p < 0.05).

Conclusions: Though prevalent in our population, sarcopenia was not associated with an increase in postoperative complications, surgical site occurences/infections,  or hernia recurrence when previously published oncologic sarcopenia cutoffs were utilized. Previously established sarcopenia outcomes in malignancy may be attributable to an altered metabolic state that is not present in hernia repair patients. Larger-scale studies are recommended to establish new sarcopenia cutoffs for VHRs.
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http://dx.doi.org/10.1007/s10029-018-1770-8DOI Listing
August 2018

Stapled Transabdominal Ostomy Reinforcement with retromuscular mesh (STORRM): Technical details and early outcomes of a novel approach for retromuscular repair of parastomal hernias.

Am J Surg 2018 Jan 21;215(1):82-87. Epub 2017 Jul 21.

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

Background: Parastomal hernia repair (PHR) remains a challenge with no optimal repair technique. During retromuscular hernia repair, traversing the stomal conduit through the abdominal wall can result in angulation and compression. Widening of traditional cruciate incisions in mesh and/or fascia likely contributes to recurrences. To address these pitfalls, the Stapled Transabdominal Ostomy Reinforcement with Retromuscular Mesh (STORRM) technique utilizing a circular stapler was developed.

Methods: A prospective registry of consecutive patients undergoing STORRM was analyzed. We characterized demographics, hernia characteristics, and perioperative results. Primary outcomes were complications, surgical site events (SSEs) and hernia recurrence.

Results: 12 patients underwent PHR with STORRM; mean age 64 and BMI 36 kg/m2. Synthetic mesh was used in 92% of patients. We observed two (17%) SSEs, one case of cellulitis and one organ space infection. With mean 12.8-month follow-up, we documented two recurrences.

Conclusions: STORRM represents a safe method to repair parastomal hernias. The unified aperture with stapled reinforcement results in reproducible repairs, minimizing intestinal angulation associated with traditional stoma passage. Early outcomes evidenced minimal complications and favorable recurrence rate.
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http://dx.doi.org/10.1016/j.amjsurg.2017.07.030DOI Listing
January 2018

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

Outcomes of Posterior Component Separation With Transversus Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement.

Ann Surg 2016 08;264(2):226-32

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

Objective: To evaluate the safety and efficacy of transversus abdominis muscle release (TAR) with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients.

Background: Posterior component separation via TAR during abdominal wall reconstruction (AWR) continues to gain popularity. Although our early experience with TAR has been promising, long-term outcomes have not been reported.

Methods: From December 2006 to December 2014, consecutive patients undergoing open AWR utilizing TAR were identified in our prospectively maintained database and reviewed retrospectively. Main outcome measures included demographics, perioperative details, wound complications, and recurrences.

Results: During the study period, 428 consecutive TAR procedures were analyzed. Mean age was 58, with mean body mass index 34.4 kg/m (range 20-65). Major comorbidities included diabetes (21%), chronic obstructive pulmonary disease (12%), and immunosuppression (3%). Mean hernia defect area was 606 cm (range 180-1280) and average mesh size was 1220 cm (range 600-4500). The majority of cases (66%) were clean, 26% were clean-contaminated, and 8% were contaminated. Eighty (18.7%) surgical-site events occurred, of which 39 (9.1%) were surgical-site infections. Three patients required mesh debridement; however, no instances of mesh explantation occurred. Of the 347 (81%) patients with at least 1-year follow-up (mean 31.5 mo), there were 13 (3.7%) recurrences.

Conclusions: Complex AWR represents a formidable surgical challenge. In this large series, we demonstrated that posterior component separation via TAR with wide synthetic mesh sublay provides a very durable repair with low morbidity, even in comorbid patients with large defects. We strongly advocate TAR as a robust addition to the armamentarium of reconstructive surgeons.
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http://dx.doi.org/10.1097/SLA.0000000000001673DOI Listing
August 2016

Pediatric Rectal Exam: Why, When, and How.

Curr Gastroenterol Rep 2016 Jan;18(1)

Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, Centennial Building, 1685 Highland Ave, Madison, WI, 53705-2281, USA.

The digital rectal examination (DRE) is performed in children less often than is indicated. Indications for the pediatric DRE include diarrhea, constipation, fecal incontinence, abdominal pain, gastrointestinal bleeding, and anemia. Less well-recognized indications may include abdominal mass, urinary symptoms, neurologic symptoms, urogenital or gynecologic symptoms, and anemia. Indeed, we believe that it should be considered part of a complete physical examination in children presenting with many different complaints. Physicians avoid this part of the physical examination in both children and adults for a number of reasons: discomfort on the part of the health care provider; belief that no useful information will be provided; lack of adequate training and experience in the performance of the DRE; conviction that planned "orders" or testing can obviate the need for the DRE; worry about "assaulting" a patient, particularly one who is small, young, and subordinate; anticipation that the exam will be refused by patient or parent; and concern regarding the time involved in the exam. The rationale and clinical utility of the DRE will be summarized in this article. In addition, the components of a complete pediatric DRE, along with suggestions for efficiently obtaining the child's consent and cooperation, will be presented.
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http://dx.doi.org/10.1007/s11894-015-0478-5DOI Listing
January 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

Repair of massive ventral hernias with "quilted" mesh.

Hernia 2015 Jun 9;19(3):465-72. Epub 2015 Apr 9.

Department of Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.

Introduction: Prosthetic reinforcement is a critical component of hernia repair. For massive defects, mesh overlap is often limited by the dimensions of commercially available implants. In scenarios where larger mesh prosthetics are required for adequate reinforcement, it may be necessary to join several pieces of mesh together using non-absorbable suture. Here, we report our outcomes for abdominal wall reconstructions in which "quilted" mesh was utilized for fascial reinforcement.

Methods: Patients undergoing open incisional hernia repair utilizing posterior component separation and transversus abdominis muscle release, with use of quilted synthetic mesh placed in the retromuscular position, were reviewed. Main outcome measures included patient, hernia, and operative characteristics and post-operative outcomes, including surgical site occurrence (SSO), surgical site infection (SSI), and recurrence.

Results: Thirty-two patients (mean age 55.7 ± 9.3, BMI 38.3 ± 5.8 kg/m(2)) underwent open ventral hernia repair with "quilted" mesh placed in the retromuscular position. The mean defect area was 760.1 ± 311.0 cm(2) with a mean width of 24.7 ± 6.4 cm. Quilted meshes consisted of two-piece (69 %), three-piece (19 %) and four-piece (12 %) configurations. Wound morbidity consisted of eight (25 %) SSOs, including four (13 %) SSIs, all of which resolved without mesh excision. With mean follow-up of 9.0 ± 13.6 months, there were two (6.3 %) lateral recurrences, both unassociated with mesh-to-mesh suture line failure.

Conclusions: Massive ventral hernias that require giant mesh prosthetics, currently not commercially available, may be successfully repaired using multiple mesh pieces sewn together in a quilt-like fashion. Such retromuscular repairs are durable, without added morbidity due to the mesh-to-mesh suture line. However, additional operative time is required for quilting the mesh together, prompting strong calls for manufacturing of larger mesh prosthetics.
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http://dx.doi.org/10.1007/s10029-015-1375-4DOI Listing
June 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

Real-time cadaveric laparoscopy and laparoscopic video demonstrations in gross anatomy: an observation of impact on learning and career choice.

Am Surg 2015 Jan;81(1):96-100

University of Connecticut School of Medicine, Farmington, Connecticut, USA.

Medical curricula are continually evolving and increasing clinical relevance. Gross anatomy educators have tested innovations to improve the clinical potency of anatomic dissection and found that clinical correlations are an effective method to accomplish this goal. Recently, surgical educators defined a role for laparoscopy in teaching anatomy. We aimed to expand this role by using surgical educators to create clinical correlates between gross anatomy and clinical surgery. We held supplements to traditional anatomy open dissection for medical students, including viewing prerecorded operative footage and live laparoscopic dissection performed on cadavers. The main outcome measures were assessed through pre- and postsession surveys. Greater than 75 per cent of students found the demonstrations highly valuable, and students perceived a significant increase in their understanding of abdominopelvic anatomy (P < 0.01). Additionally, 62 per cent of students with previous interest in surgery and 10 per cent of students without previous interest in surgery reported increased interest in pursuing surgical careers. Our demonstrations advance the use of minimally invasive surgical technology to teach gross anatomy. Live laparoscopic demonstrations augment traditional anatomic instruction by reinforcing the clinical relevance of abdominopelvic anatomy. Additionally, laparoscopic demonstrations generate interest in surgery that would otherwise be absent in the preclinical years.
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January 2015

Laparoscopic-assisted drainage of a massive retroperitoneal abscess caused by group B Streptococcus.

Surg Infect (Larchmt) 2015 Feb 14;16(1):110-1. Epub 2014 Nov 14.

1 University of Connecticut Health Center , Farmington, Connecticut.

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http://dx.doi.org/10.1089/sur.2014.041DOI Listing
February 2015

Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy.

Surg Endosc 2015 May 24;29(5):1064-70. Epub 2014 Sep 24.

Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.

Introduction: Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients who have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients who have undergone POEM and compare outcomes between patients who have or have not received previous treatment for achalasia.

Methods And Procedures: We evaluated our prospectively collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and postoperative GERD-Health-Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring.

Results: Forty patients received a POEM procedure between 2011 and 2013. Of these, 40% (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Prior Tx) and 118 min for patients without any prior procedure (No Tx) (p = 0.07). Intraoperative complication rates for the Prior Tx group were 12.5 versus 16.7% for the No Tx group. Mean follow-up was 10 months. Both groups independently demonstrated clinical improvement in both the GERD-HRQL and SF-12 scores following POEM. There were no statistical differences between the two groups for GERD-HRQL reflux and dysphagia subset scores, or SF-12 mental component summary.

Conclusion: We found favorable outcomes following POEM in patients who have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no significant differences between these two groups with regards to operative times, GERD-HRQL scores, and mental component SF-12 scores. One complication requiring intervention occurred in a patient that had received multiple prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.
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http://dx.doi.org/10.1007/s00464-014-3782-5DOI Listing
May 2015

Prenatal organochlorine and methylmercury exposure and memory and learning in school-age children in communities near the New Bedford Harbor Superfund site, Massachusetts.

Environ Health Perspect 2014 Nov 6;122(11):1253-9. Epub 2014 Aug 6.

Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA.

Background: Polychlorinated biphenyls (PCBs), organochlorine pesticides, and methylmercury (MeHg) are environmentally persistent with adverse effects on neurodevelopment. However, especially among populations with commonly experienced low levels of exposure, research on neurodevelopmental effects of these toxicants has produced conflicting results.

Objectives: We assessed the association of low-level prenatal exposure to these contaminants with memory and learning.

Methods: We studied 393 children, born between 1993 and 1998 to mothers residing near a PCB-contaminated harbor in New Bedford, Massachusetts. Cord serum PCB, DDE (dichlorodiphenyldichloroethylene), and maternal peripartum hair mercury (Hg) levels were measured to estimate prenatal exposure. Memory and learning were assessed at 8 years of age (range, 7-11 years) using the Wide Range Assessment of Memory and Learning (WRAML), age-standardized to a mean ± SD of 100 ± 15. Associations with each WRAML index-Visual Memory, Verbal Memory, and Learning-were examined with multivariable linear regression, controlling for potential confounders.

Results: Although cord serum PCB levels were low (sum of four PCBs: mean, 0.3 ng/g serum; range, 0.01-4.4), hair Hg levels were typical of the U.S. fish-eating population (mean, 0.6 μg/g; range, 0.3-5.1). In multivariable models, each microgram per gram increase in hair Hg was associated with, on average, decrements of -2.8 on Visual Memory (95% CI: -5.0, -0.6, p = 0.01), -2.2 on Learning (95% CI: -4.6, 0.2, p = 0.08), and -1.7 on Verbal Memory (95% CI: -3.9, 0.6, p = 0.14). There were no significant adverse associations of PCBs or DDE with WRAML indices.

Conclusions: These results support an adverse relationship between low-level prenatal MeHg exposure and childhood memory and learning, particularly visual memory.
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http://dx.doi.org/10.1289/ehp.1307804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216164PMC
November 2014

Retrograde myotomy: a variation in per oral endoscopic myotomy (POEM) technique.

Surg Endosc 2014 Nov 31;28(11):3257-9. Epub 2014 May 31.

Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA,

Background: Per oral endoscopic myotomy (POEM) has evolved as a novel therapeutic option for the treatment of esophageal motility disorders such as achalasia. The originally described dissection technique involves cutting the inner circular esophageal muscle fibers in an antegrade fashion. We have modified this technique by commencing the muscular division at the most distal aspect of the submucosal tunnel and continuing the dissection in a retrograde fashion. We present our initial series of patients performed using this modified technique.

Methods: We retrospectively reviewed our prospectively collected database. Peri- and postoperative data were collected and analyzed. POEM procedures were performed in a near-identical manner as previously published.

Results: Retrograde myotomy was performed on five patients with a diagnosis of achalasia. Four had a history of prior treatment including balloon dilation, with one of these having a prior surgical myotomy. Retrograde POEM procedures were performed with trace blood loss and without any complications. Mean operative time was 85 min. All patients had normal esophagram studies, and diets were advanced as per protocol.

Conclusion: POEM was developed as a minimally invasive method for the treatment of achalasia. Our retrograde dissection modification allows the most critical portion of the case, namely division of the lower esophageal and upper gastric circular muscle fibers, to be performed earlier in the case. This ensures adequate dissection of the primary site of esophageal dysfunction should problems arise during the procedure. The modification is straightforward, without the need for additional training or equipment, and appears to provide a more rapid myotomy with less charring in this small cohort of patients.
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http://dx.doi.org/10.1007/s00464-014-3568-9DOI Listing
November 2014

Technical aspects of bile duct evaluation and exploration.

Surg Clin North Am 2014 Apr 28;94(2):281-96. Epub 2014 Jan 28.

University Hospitals Case Medical Center, Cleveland, OH, USA. Electronic address:

Choledocholithiasis is a common manifestation of biliary disease. Intraoperative cholangiography can be performed in several ways. Common bile duct exploration can be safely performed but necessitates an advanced level of surgical experience to limit complications and improve success. An algorithm based on available resources and the physician skill set is vital for safe and effective management of choledocholithiasis. Endoscopic retrograde cholangiopancreatography requires the availability of an advanced endoscopist as well as significant equipment and resources. Current training of young surgeons is limited for open biliary procedures and common bile duct explorations. Educational guidelines are necessary to reduce this educational gap.
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http://dx.doi.org/10.1016/j.suc.2013.12.002DOI Listing
April 2014

Central failures of lightweight monofilament polyester mesh causing hernia recurrence: a cautionary note.

Hernia 2015 Feb;19(1):155-9

Introduction: Uncoated, lightweight, macroporous,monofilament mesh has been shown to demonstrate improved bacterial clearance, better tissue integration,reduced foreign body response, and less chronic pain with equivalent durability for hernia repair. These findings led us to use a new lightweight monofilament polyester mesh (Parietex TCM, Covidien). Here, we report our experience with this mesh in open incisional hernia repair.

Methods: Patients undergoing incisional hernia repair with Parietex TCM were retrospectively identified within our prospectively maintained database. Patient demographics,operative characteristics, and follow-up were reviewed. Outcome parameters included 90-day wound morbidity and hernia recurrence.

Results: In 2011, 36 patients (mean age 56.8; mean BMI32.4 kg/m2) underwent open incisional hernia repair with retrorectus mesh placement by two surgeons (MJR, YWN) at Case Medical Center. Anterior and posterior fascial closure was achieved in all cases. Wound morbidity included seven surgical site occurrences: four superficial infections that resolved with antibiotics, one wound dehiscence requiring wet-to-dry packing, and two seromas that resolved without intervention. With a mean follow-up of 13 months, 8 (22%) recurrences have occurred. On reoperation, 7 (19%) of these patients had mechanical failure or fracturing of the mesh. No confounding variables were identified by univariate analysis of patient demographics,operative characteristics, or wound morbidity.

Conclusion: Lightweight monofilament polyester mesh (Parietex TCM) appears to have a high incidence of mechanical failure in the context of open incisional hernia repair. While this limitation may ultimately be revealed asa weakness of all lightweight mesh, surgeons should be aware that these failures have already been documented.
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http://dx.doi.org/10.1007/s10029-014-1237-5DOI Listing
February 2015

Comparative analysis of histopathologic responses to implanted porcine biologic meshes.

Hernia 2014 Oct 27;18(5):713-21. Epub 2013 Dec 27.

Department of Surgery, University of Connecticut Health Center, Farmington, CT, USA,

Objectives: Biologic mesh (BM) prostheses are increasingly utilized for hernia repairs. Modern BMs are not only derived from different tissue sources, but also undergo various proprietary processing steps-factors that likely impact host tissue responses and mesh performance. We aimed to compare histopathologic responses to various BMs after implantation in a mouse model.

Materials And Methods: Five-mm samples of non-crosslinked [Strattice (ST)], and intentionally crosslinked [CollaMend (CM), Permacol (PC)] porcine-derived biologic meshes were implanted subcutaneously in C57BL/6 mice. 1, 4, 8, and 12 weeks post-implantation, meshes were assessed for inflammation, foreign body reaction (FBR), neocellularization, and collagen deposition using H&E and trichrome stains.

Results: All meshes induced early polymorphonuclear cell infiltration (highest in CM; lowest in ST) that resolved by 4 weeks. ST was associated with extensive macrophage presence at 12 weeks. Foreign body response was not seen in the ST group, but was present abundantly in the CM and PC groups, highest at 8 weeks. New peripheral collagen deposition was seen only in the ST group at 12 weeks. Collagen organization was highest in the ST group as well. Both CM and PC groups were associated with fibrous encapsulation and no evidence of integration or remodeling.

Conclusions: Inflammation appears to be a common component of integration of all biologic meshes studied. Pronounced inflammatory responses as well as profound FBR likely lead to observed encapsulation and poor host integration of the crosslinked BMs. Overall, ST was associated with the lowest foreign body response and the highest degree of new collagen deposition and organization. These features may be key predictors for improved mesh performance during hernia repair.
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http://dx.doi.org/10.1007/s10029-013-1203-7DOI Listing
October 2014

Laparoscopic placement of adjustable gastric band in patients with autoimmune disease or chronic steroid use.

Obes Surg 2014 Apr;24(4):584-7

Department of Surgery, Texas Tech University Health Sciences Center, 3601 Fourth St, Lubbock, TX, 79430, USA,

Background: Past medical or family history of autoimmune diseases and patient chronic steroid use are label contraindications for laparoscopic placement of adjustable gastric band (LAGB). We reviewed our experience with placement of LAGB in patients with autoimmune disease or chronic steroid use.

Methods: This was a retrospective review of our prospective bariatric database. All patients who underwent LAGB and had a diagnosis of autoimmune disease or chronic steroid use with at least 1-year follow-up data were included in the study. Data on demographics, weight loss, and complications were collected.

Results: Sixteen patients with autoimmune diseases or chronic steroid use underwent LAGB. Diseases included were lupus (n = 6), sarcoidosis (n = 4), renal transplant (n = 2), rheumatoid arthritis (n = 1), ulcerative colitis (n = 1), Grave's disease (n = 1), and celiac disease (n = 1). No patients developed infectious complications. One patient required port replacement due to malfunction, and one patient underwent a conversion to gastric bypass due to failure of weight loss. The average preoperative body mass index was 46.8 kg/m(2) with an average weight of 292.0 lbs. Average excess weight loss was 39.8 % (range, 7.4 to 95.5 %) at a median follow-up of 54 months.

Conclusions: Our review indicates that LAGB in patients with autoimmune diseases or chronic steroid use is safe, with no infectious complications and only one explant. Some of these autoimmune conditions may improve following significant weight loss, but larger studies are required to further substantiate these findings.
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http://dx.doi.org/10.1007/s11695-013-1122-9DOI Listing
April 2014

Infant GERD: symptoms, reflux episodes & reflux disease, acid & non-acid refllux--implications for treatment with PPIs.

Curr Gastroenterol Rep 2013 Nov;15(11):353

University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,

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http://dx.doi.org/10.1007/s11894-013-0353-1DOI Listing
November 2013

Autophagy failure in Alzheimer's disease and the role of defective lysosomal acidification.

Eur J Neurosci 2013 Jun;37(12):1949-61

Center for Dementia Research, Nathan S Kline Institute, 140 Old Orangeburg Road, Orangeburg, NY 10962, USA.

Autophagy is a lysosomal degradative process which recycles cellular waste and eliminates potentially toxic damaged organelles and protein aggregates. The important cytoprotective functions of autophagy are demonstrated by the diverse pathogenic consequences that may stem from autophagy dysregulation in a growing number of neurodegenerative disorders. In many of the diseases associated with autophagy anomalies, it is the final stage of autophagy-lysosomal degradation that is disrupted. In several disorders, including Alzheimer's disease (AD), defective lysosomal acidification contributes to this proteolytic failure. The complex regulation of lysosomal pH makes this process vulnerable to disruption by many factors, and reliable lysosomal pH measurements have become increasingly important in investigations of disease mechanisms. Although various reagents for pH quantification have been developed over several decades, they are not all equally well suited for measuring the pH of lysosomes. Here, we evaluate the most commonly used pH probes for sensitivity and localisation, and identify LysoSensor yellow/blue-dextran, among currently used probes, as having the optimal profile of properties for measuring lysosomal pH. In addition, we review evidence that lysosomal acidification is defective in AD and extend our original findings, of elevated lysosomal pH in presenilin 1 (PS1)-deficient blastocysts and neurons, to additional cell models of PS1 and PS1/2 deficiency, to fibroblasts from AD patients with PS1 mutations, and to neurons in the PS/APP mouse model of AD.
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http://dx.doi.org/10.1111/ejn.12169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3694736PMC
June 2013

Effect of patient and hospital characteristics on outcomes of elective ventral hernia repair in the United States.

Hernia 2013 Oct 24;17(5):639-45. Epub 2013 Apr 24.

Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA,

Purposes: Our ability to predict complications of ventral hernia repairs (VHR) are inadequate. Although impact of patient comorbidities and hospital characteristics on outcomes of several surgical procedures has been reported, such analysis on elective herniorrhaphy has not been performed to date. We hypothesized that obesity and diabetes as well as socioeconomic factors would have deleterious outcomes on elective VHR.

Methods: Analysis of 2004-2008 Nationwide Inpatient Sample database. Main outcome measures included wound/systemic morbidity, length of stay, discharge status, and in-hospital mortality. Bivariate and multivariate analyses were performed to assess influence of diabetes, obesity, patient socioeconomic factors, and hospital characteristics on the outcomes of VHR.

Results: A total of 78,348 adults undergoing elective VHR were analyzed. Obesity had significant risks for cardiopulmonary complications and prolonged hospitalization. Diabetics were more likely to have delayed wound healing. Hispanic patients had significantly higher rates of pulmonary complications and mortality. As compared to private insurance patients, Medicaid and Medicare patients had significantly higher odds of complications, prolonged hospitalization, non-routine discharge, and mortality.

Conclusion: Obesity and diabetes appear to be significant predictors of morbidity in patients undergoing elective VHR. Alarmingly, Medicare/Medicaid patients not only had the highest rates of wound/systemic complications but also the highest post-operative mortality. For the first time, we demonstrated that in addition to comorbidities, both patient socioeconomic factors and hospital characteristics appear to be major determinants of post-herniorrhaphy complications and mortalities. Improved health maintenance and reduction in income-related disparities in health care delivery may be paramount in improving outcomes of VHR in the United States.
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http://dx.doi.org/10.1007/s10029-013-1088-5DOI Listing
October 2013

Interplay of LRRK2 with chaperone-mediated autophagy.

Nat Neurosci 2013 Apr 3;16(4):394-406. Epub 2013 Mar 3.

Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, USA.

Mutations in leucine-rich repeat kinase 2 (LRRK2) are the most common cause of familial Parkinson's disease. We found LRRK2 to be degraded in lysosomes by chaperone-mediated autophagy (CMA), whereas the most common pathogenic mutant form of LRRK2, G2019S, was poorly degraded by this pathway. In contrast to the behavior of typical CMA substrates, lysosomal binding of both wild-type and several pathogenic mutant LRRK2 proteins was enhanced in the presence of other CMA substrates, which interfered with the organization of the CMA translocation complex, resulting in defective CMA. Cells responded to such LRRK2-mediated CMA compromise by increasing levels of the CMA lysosomal receptor, as seen in neuronal cultures and brains of LRRK2 transgenic mice, induced pluripotent stem cell-derived dopaminergic neurons and brains of Parkinson's disease patients with LRRK2 mutations. This newly described LRRK2 self-perpetuating inhibitory effect on CMA could underlie toxicity in Parkinson's disease by compromising the degradation of α-synuclein, another Parkinson's disease-related protein degraded by this pathway.
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http://dx.doi.org/10.1038/nn.3350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3609872PMC
April 2013

Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction.

Am J Surg 2012 Nov 16;204(5):709-16. Epub 2012 May 16.

Department of Surgery, University of Connecticut Health Center, Farmington, CT, USA.

Background: Several modifications of the classic retromuscular Stoppa technique to facilitate dissection beyond the lateral border of the rectus sheath recently were reported. We describe a novel technique of transversus abdominis muscle release (TAR) for posterior component separation during major abdominal wall reconstructions.

Methods: Retrospective review of consecutive patients undergoing TAR. Briefly, the retromuscular space is developed laterally to the edge of the rectus sheath. The posterior rectus sheath is incised 0.5-1 cm underlying medial to the linea semilunaris to expose the medial edge of the transversus abdominis muscle. The muscle then is divided, allowing entrance to the space anterior to the transversalis fascia. The posterior rectus fascia then is advanced medially. The mesh is placed as a sublay and the linea alba is restored ventral to the mesh.

Results: Between December 2006 and December 2009, we have used this technique successfully in 42 patients with massive ventral defects. Thirty-two (76.2%) patients had recurrent hernias. The average mesh size used was 1,201 ± 820 cm(2) (range, 600-2,700). Ten (23.8%) patients developed various wound complications requiring reoperation/debridement in 3 patients. At a median follow-up period of 26.1 months, there have been 2 (4.7%) recurrences.

Conclusions: Our novel technique for posterior component separation was associated with a low perioperative morbidity and a low recurrence rate. Overall, transversus abdominis muscle release may be an important addition to the armamentarium of surgeons undertaking major abdominal wall reconstructions.
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http://dx.doi.org/10.1016/j.amjsurg.2012.02.008DOI Listing
November 2012

Comparative analysis of histopathologic effects of synthetic meshes based on material, weight, and pore size in mice.

J Surg Res 2012 Aug 11;176(2):423-9. Epub 2011 Oct 11.

Department of Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA.

Background: While synthetic prosthetics have essentially become mandatory for hernia repair, mesh-induced chronic inflammation and scarring can lead to chronic pain and limited mobility. Mesh propensity to induce such adverse effects is likely related to the prosthetic's material, weight, and/or pore size. We aimed to compare histopathologic responses to various synthetic meshes after short- and long-term implantations in mice.

Material And Methods: Samples of macroporous polyester (Parietex [PX]), heavyweight microporous polypropylene (Trelex[TX]), midweight microporous polypropylene (ProLite[PL]), lightweight macroporous polypropylene (Ultrapro[UP]), and expanded polytetrafluoroethylene (DualMesh[DM]) were implanted subcutaneously in mice. Four and 12 wk post-implantation, meshes were assessed for inflammation, foreign body reaction (FBR), and fibrosis.

Results: All meshes induced varying levels of inflammatory responses. PX induced the greatest inflammatory response and marked FBR. DM induced moderate FBR and a strong fibrotic response with mesh encapsulation at 12 wk. UP and PL had the lowest FBR, however, UP induced a significant chronic inflammatory response. Although inflammation decreased slightly for TX, marked FBR was present throughout the study. Of the three polypropylene meshes, fibrosis was greatest for TX and slightly reduced for PL and UP. For UP and PL, there was limited fibrosis within each mesh pore.

Conclusion: Polyester mesh induced the greatest FBR and lasting chronic inflammatory response. Likewise, marked fibrosis and encapsulation was seen surrounding ePTFE. Heavier polypropylene meshes displayed greater early and persistent fibrosis; the reduced-weight polypropylene meshes were associated with the least amount of fibrosis. Mesh pore size was inversely proportional to bridging fibrosis. Moreover, reduced-weight polypropylene meshes demonstrated the smallest FBR throughout the study. Overall, we demonstrated that macroporous, reduced-weight polypropylene mesh exhibited the highest degree of biocompatibility at sites of mesh implantation.
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http://dx.doi.org/10.1016/j.jss.2011.09.031DOI Listing
August 2012

Evaluation of serum cytokine release in response to hand-assisted, laparoscopic, and open surgery in a porcine model.

Am J Surg 2011 Jul;202(1):97-102

Department of Surgery, University of Connecticut Health Center, Farmington, 06030, USA.

Background: Although the immunologic benefits of laparoscopic surgery have been established, effects from hand-assisted (HA) surgery have not been investigated thoroughly. We hypothesized that the HA approach maintains the immunologic advantage of laparoscopic surgery compared with the open (O) approach.

Methods: Six O, HA, and laparoscopic (L) transabdominal left nephrectomies were performed on pigs. Blood samples were taken preoperatively, perioperatively, and postoperatively, and serum interleukin-6 and C-reactive protein levels were measured.

Results: At 24 hours after surgery, interleukin-6 levels were significantly higher in the O group vs the HA and L groups (82.2 vs 37.5 and 29.9 pg/mL, respectively; P < .05). Similar trends were seen at all time periods for both IL-6 and C-reactive protein. No significant differences in postoperative cytokine levels were detected between the HA and L groups.

Conclusions: The HA approach mimics the immunologic effects of laparoscopic surgery. These data suggest that the HA technique resulted in a reduced systemic immune activation in the early perioperative period when compared with open surgery. In addition to clinical benefits of minimal access, the HA approach also may afford patients an immunologic advantage over laparotomy.
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http://dx.doi.org/10.1016/j.amjsurg.2010.09.026DOI Listing
July 2011

Development and psychometric evaluation of 2 age-stratified versions of the Pediatric GERD Symptom and Quality of Life Questionnaire.

J Pediatr Gastroenterol Nutr 2011 May;52(5):514-22

United BioSource Corporation, Bethesda, MD 20814, USA.

Objectives: The Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire (PGSQ) represents 2 related age-stratified tools developed to assess pediatric gastroesophageal reflux disease (GERD). These include the PGSQ-Cp (for children ages 2 to 8 years, parent/caregiver report) and the PGSQ-A (for adolescents ages 9-17 years). The objective of the present study was to develop and evaluate PGSQ measurement properties.

Materials And Methods: The PGSQ items were generated based on information from focus groups, expert clinician review, and cognitive debriefing interviews. The symptoms of pediatric GERD and the effect of these symptoms were addressed. The tools were evaluated in a 3-week psychometric evaluation with participants from 11 clinical sites in the United States. The study included other measures such as the Pediatric Quality of Life questionnaire (PedsQL) and clinician-rated GERD severity. After item reduction, internal consistency, reproducibility, construct validity, known-group validity, and responsiveness were assessed.

Results: The 231 participants included 75 parents of children ages 2 to 8 years and 75 children ages 9 to 17 years with GERD and 41 parents of children and 40 children ages 9 to 17 years without GERD. Exploratory factor analysis demonstrated 4 symptom subscales for the PGSQ-Cp and 3 symptom subscales for the PGSQ-A. Both had subscales for total impact and school impact. High to moderate internal consistency was observed, ranging from 0.76 to 0.96 for the PGSQ-Cp and from 0.67 to 0.94 for the PGSQ-A. The PGSQ significantly differentiated between patients with GERD and controls (P < 0.0001, PGSQ-Cp; P < 0.0022-0.0001, PGSQ-A) and demonstrated responsiveness.

Conclusions: These results support the reliability, validity, and responsiveness of both versions of the PGSQ. The instruments should be useful for clinical studies.
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http://dx.doi.org/10.1097/MPG.0b013e318205970eDOI Listing
May 2011

Chaperone-mediated autophagy at a glance.

J Cell Sci 2011 Feb;124(Pt 4):495-9

Department of Developmental and Molecular Biology and Institute for Aging Studies, Albert Einstein College of Medicine, Bronx, NY 10461, USA.

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http://dx.doi.org/10.1242/jcs.073874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031365PMC
February 2011

Outcomes of laparoscopic ventral hernia repair with routine defect closure using "shoelacing" technique.

Surg Endosc 2011 May 5;25(5):1452-7. Epub 2010 Nov 5.

Department of Surgery, Connecticut Comprehensive Center for Hernia Repair, University of Connecticut Health Center, 263 Farmington Avenue-MC 3955, Farmington, CT 06030, USA.

Introduction: Laparoscopic approach has become standard for many ventral hernia repairs. The benefits of minimal access include reduced wound complications, faster functional recovery, and improved cosmesis, among others. However, "bridging" of hernia defects during traditional laparoscopic ventral hernia repair (LVHR) often leads to seromas or bulging and, importantly, does not restore a functional abdominal wall. We have modified our approach to LVHR to routinely utilize transabdominal defect closure ("shoelacing" technique) prior to mesh placement. Herein, we aim to analyze outcomes of LVHR with shoelacing.

Methods: Consecutive patients undergoing LVHR with shoelacing were reviewed retrospectively. Main outcome measures included patient demographics, previous surgical history, intraoperative time, mesh type and size, postoperative complications, length of hospitalization, and hernia recurrence.

Results: Forty-seven consecutive patients underwent LVHR with defect closure. Average body mass index (BMI) was 32 kg/m2 (range 22-50 kg/m2). Eighteen (38%) patients had an average of 1.5 previous repairs (range 1-3). Mean defect size was 82 cm2 (range 16-300 cm2), requiring a median of 4 (range 2-7) transabdominal stitches for shoelacing. Two patients required endoscopic component separation to facilitate defect closure. Mean mesh size used was 279 cm2 (range 120-600 cm2). Mean operative time was 134 min (range 40-280 min). There were no intraoperative complications. Average length of hospitalization was 2.9 days (range 1-10 days). There were two major postoperative complications [one pulmonary embolism (PE), one stroke]; however, there was no wound-related morbidity or significant seromas. At mean follow-up of 16.2 months, there have been no recurrences.

Conclusions: LVHR with defect closure confers a strong advantage in hernia repair, shifting the paradigm towards more physiologic abdominal wall reconstruction. In this series, we found our approach to be safe and comparable to historic controls. While providing reliable hernia repair, the addition of defect closure in our patients essentially eliminated postoperative seroma. We advocate routine use of the shoelace technique during laparoscopic ventral hernia repair.
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http://dx.doi.org/10.1007/s00464-010-1413-3DOI Listing
May 2011