Publications by authors named "Y W Novitsky"

146 Publications

Critical view of robotic-assisted transverse abdominal release (r-TAR).

Hernia 2021 Apr 2. Epub 2021 Apr 2.

Creighton University School of Medicine-Phoenix, Phoenix, USA.

Introduction: Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures.

Description Of The Technique: We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains.

Discussion: Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.
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http://dx.doi.org/10.1007/s10029-021-02391-yDOI Listing
April 2021

Simulation in Hernia Surgery: Where Do We Stand?

J Laparoendosc Adv Surg Tech A 2021 Mar 10. Epub 2021 Mar 10.

Comprehensive Hernia Center, Columbia University Medical Center, New York, New York, USA.

Simulation seems to be the best method of improving medical attitude, technical skills, and operating times. A literature review of the available data in simulation for hernia surgery was performed. Surgical simulation has been included as a main requirement in residency programs and endorsed by several surgical societies. However, evaluating how simulation affects patient's outcomes is challenging. In addition, simulation training represents an institutional economic burden that could undermine its implementation and development. Published data support that simulation-based training is a highly efficient tool, thus, its implementation should be strongly encouraged.
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http://dx.doi.org/10.1089/lap.2021.0081DOI Listing
March 2021

Robotic-Assisted Transabdominal Preperitoneal Ventral Hernia Repair.

Surg Technol Int 2020 May;36:95-97

Comprehensive Hernia Center, Columbia University Medical Center, New York, NY.

Ventral hernia repair is one of the most common operations performed by surgeons worldwide. The widespread adoption of laparoscopic surgery has significantly reduced complications related to traditional open approaches. The most common approach in laparoscopic ventral hernia repair is the intraperitoneal onlay mesh (IPOM) approach. This technique, though simple to perform, has limitations, including bridging mesh, intraperitoneal positioning of mesh, transfascial fixation, circumferential mesh fixation, and the use of more expensive composite mesh materials. These limitations are magnified when hernias occur in anatomically difficult sites such as the subxiphoid, suprapubic, and flank regions. Robotic-assisted hernia repair using a transabdominal preperitoneal (TAPP) approach has emerged as a viable alternative to traditional IPOM by potentially addressing these limitations. We review the operative considerations, intraoperative approach, and current body of literature related to robotic-assisted TAPP ventral hernia repair and conclude that it is feasible and may result in improved outcomes related to the restoration of abdominal wall anatomy and reduced operative costs. Further studies are needed to assess if robotic-assisted TAPP should become the standard approach for repair of ventral hernia defects.
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May 2020

Robotic Inguinal Hernia Repair.

Surg Clin North Am 2020 Apr 1;100(2):409-415. Epub 2020 Feb 1.

Columbia University Medical Center, Comprehensive Hernia Center, Department of Surgery, 161 Fort Washington Avenue, New York, NY 10032, USA. Electronic address:

Robotic inguinal hernia repair represents the natural progression of minimally invasive inguinal hernia surgery. This article highlights all aspects of a robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair with mesh, starting with preoperative planning and patient selection, key technical steps, and common postoperative complications and recovery. The most recent published data on robotic inguinal hernia repair are comprehensively reviewed, confirming that rTAPP is a safe and effective option for the repair of unilateral and bilateral inguinal hernias.
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http://dx.doi.org/10.1016/j.suc.2019.12.010DOI Listing
April 2020

Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model.

Surg Endosc 2020 06 9;34(6):2682-2689. Epub 2019 Aug 9.

Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Background: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model.

Methods: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann-Whitney U test. Values are represented as average myofascial medialization in centimeters.

Results: Following MLL an average of 5.0 ± 0.9 cm (range 3.4-6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3-10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6-12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535.

Conclusions: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen.
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http://dx.doi.org/10.1007/s00464-019-07046-9DOI Listing
June 2020

Farewell from the Hernia Editorial Team.

Hernia 2018 12 10;22(6):897-898. Epub 2018 Oct 10.

, New York, USA.

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http://dx.doi.org/10.1007/s10029-018-1810-4DOI Listing
December 2018

SSI, SSO, SSE, SSOPI: the elusive language of complications in hernia surgery.

Hernia 2018 10 10;22(5):737-738. Epub 2018 Sep 10.

University Hospital Lund, Lund, Sweden.

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http://dx.doi.org/10.1007/s10029-018-1813-1DOI Listing
October 2018

Laparoscopic ventral hernia repair with and without defect closure: comparative analysis of a single-institution experience with 783 patients.

Hernia 2018 12 25;22(6):1061-1065. Epub 2018 Aug 25.

Department of Surgery, Cleveland Medical Center, Cleveland, OH, USA.

Background: Laparoscopic ventral hernia repair (LVHR) has gained popularity, since it can decrease the incidence of surgical site complications while providing similar recurrence rates as open repairs. The role of defect closure in LVHR has been a subject of controversy and has not been fully elucidated. We aimed to compare outcomes of LVHR with and without defect closure in a contemporary cohort.

Methods: Single-institution retrospective review of consecutive adults undergoes elective LVHR for 2-8 cm defects. Demographics, perioperative, and post-operative data were included for analysis. Surgical site events (SSE), surgical site infection (SSI), and recurrence were the main measured outcomes. Abdominal CT scan was used to differentiate true recurrence from pseudo-recurrence.

Results: A total of 783 patients were analyzed. 222 of them had their defects closed (DC), while the remaining 561 defects were not closed (NC) at the discretion/routine of the operating surgeon. Patients were slightly older in the non-closure group, while those in the defect closure group had a significantly higher BMI. There were no other differences in demographics between groups. After a mean follow-up of 12.1 months, the incidence of surgical site events (3.6 vs 14.9%, p < 0.0001) and seromas (0.4 vs 11.5%, p < 0.0001) was significantly lower in the defect closure group. Objectively confirmed recurrences were also significantly lower in the DC group (5.4 vs 14.2%, p = 0.003).

Conclusions: In our experience, the addition of defect closure can reduce the incidence of surgical site events, seroma, and hernia recurrence after LVHR. We advocate for routine closure of defects when laparoscopic repair is chosen for small-to-mid-sized ventral hernias.
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http://dx.doi.org/10.1007/s10029-018-1812-2DOI Listing
December 2018

Discussion: Anterior versus Posterior Component Separation: Which Is Better?

Plast Reconstr Surg 2018 09;142(3 Suppl):56S-57S

From the Columbia Comprehensive Hernia Center, Columbia University Medical Center; and Anne Arundel Medical Center.

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http://dx.doi.org/10.1097/PRS.0000000000004880DOI Listing
September 2018

In vivo biocompatibility and time-dependent changes in mechanical properties of woven collagen meshes: A comparison to xenograft and synthetic mid-urethral sling materials.

J Biomed Mater Res B Appl Biomater 2019 04 13;107(3):479-489. Epub 2018 Jun 13.

Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, 44106.

Meshes woven from highly aligned collagen threads crosslinked using either genipin or 1-ethyl-3-(3-dimethylaminopropyl) carboiimide and N-hydroxy succinimide (EDC/NHS) were implanted in a subcutaneous rat model to evaluate their biocompatibility (at 2 weeks, 2 months, and 5 months), mechanical properties (at baseline, 2 months, and 5 months) and ultimately their suitability for use as mid-urethral slings (MUS) for management of stress urinary incontinence. Porcine dermal (Xenmatrix) and monofilament polypropylene (Prolene) meshes were also implanted to provide comparison to clinically used materials. Quantitative histological scoring showed tissue integration in Xenmatrix was almost absent, while the open network of woven collagen and Prolene meshes allowed for cellular and tissue integration. However, strength and stiffness of genipin-crosslinked collagen (GCC), Prolene, and Xenmatrix meshes were not significantly different from those of native rectus fascia and vaginal tissues of animals at 5 months. EDC/NHS-crosslinked collagen (ECC) meshes were degraded so extensively at five months that samples could only be used for histological staining. Picrosirius red and Masson's trichrome staining revealed that integrated tissue within GCC meshes was more aligned (p = 0.02) and appeared more concentrated than ECC meshes at 5 months. Furthermore, immunohistochemical staining showed that GCC meshes attracted a greater number of cells expressing markers for M2 macrophages, those associated with regeneration, than ECC meshes (p = 0.01 for CD206+ cells, p = 0.001 CD163+ cells) at 5 months. As such, GCC meshes hold promise as a new MUS biomaterial based on favorable induction of fibrous tissue resulting in mechanical stiffness matching that of native tissue. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 479-489, 2019.
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http://dx.doi.org/10.1002/jbm.b.34138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335430PMC
April 2019

Assessment of myofascial medialization following posterior component separation via transversus abdominis muscle release in a cadaveric model.

Hernia 2018 08 30;22(4):637-644. Epub 2018 Apr 30.

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

Purpose: Posterior component separation (PCS) via the transversus abdominis release (TAR) procedure continues to gain popularity. However, neither the physiologic basis nor the extent of myofascial medialization after TAR is established. We aimed to assess both anterior and posterior rectus fascia (AF and PF) medialization following each step of the TAR procedure.

Methods: Ten fresh cadavers underwent PCS via TAR. Steps included midline laparotomy (MLL), retrorectus dissection (RRD), incision of the posterior rectus sheath (IPL), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Medial advancement of AF and PF was measured following application of 2.5, 5.0 lb, and maximal tension to the fascial edge. Values are represented as mean advancement past midline in centimeters.

Results: MLL allowed advancement of 2.5, 3.7, and 4.9 cm. RRD provided advancement of 4.1, 5.9, and 7.6 cm for AF and 4.4, 6.2, and 7.5 cm for PF. IPL provided advancement of 4.2, 6.1, and 8.0 cm for AF and 4.6, 6.6, and 8.3 cm for PF. TAD provided advancement of 4.5, 6.6, and 8.6 cm for AF and 5.3, 7.5, and 9.5 cm for PF. RMD provided advancement of 5.5, 7.9, and 9.9 cm for AF and 6.9, 9.6, and 11.2 cm for PF. Overall, the complete TAR procedure provided AF advancement of 102% and PF advancement of 129%, over baseline.

Conclusions: The TAR procedure provides for substantial medial advancement of both anterior and posterior myofascial components of the abdominal wall. Retromuscular dissection deep to the divided transversus abdominis muscle appears to be the key step of the procedure, allowing for effective reconstruction of very wide (≈ 20 cm) defects.
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http://dx.doi.org/10.1007/s10029-018-1771-7DOI Listing
August 2018

Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation.

Hernia 2018 04 18;22(2):303-309. Epub 2018 Jan 18.

Department of General Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17033, USA.

Background: A minority of patients undergoing posterior component separation (PCS) have abdominal wall defects that preclude complete reconstruction of the visceral sac with native tissue. The use of absorbable mesh bridges (AMB) to span such defects has not been established. We hypothesized that AMB use during posterior sheath closure of PCS is safe and provides favorable outcomes.

Methods: We performed a retrospective review of consecutive patients undergoing PCS with AMB at two hernia centers. Main outcome measures included demographics, comorbidities, and post-operative complications.

Results: 36 patients were identified. Post-operative wound complications included five surgical site infections. At a median of 27 months, there were five recurrent hernias (13.9%), 2 of which were parastomal, but no episodes of intestinal obstruction/fistula.

Conclusions: Utilization of AMB for large posterior layer deficits results in acceptable rates of perioperative wound morbidity, effective PCS repairs, and does not increase intestinal morbidity or fistula formation.
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http://dx.doi.org/10.1007/s10029-018-1732-1DOI Listing
April 2018

Laparoscopic repair of traumatic flank hernias.

Authors:
Y W Novitsky

Hernia 2018 04 15;22(2):363-369. Epub 2017 Dec 15.

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

Introduction: Traumatic flank hernias (TFH) are caused by a blunt abdominal trauma with resultant detachment of the oblique musculofascial complex at the iliac crest and/or costal margin. Given such proximity to the bony structures and essential absence of healthy fascia to anchor the mesh, TFH represent a challenging surgical problem. Although laparoscopic repair of ventral hernias has become very common, no series of laparoscopic repairs of TFH has been reported to date. We present a series of patients undergoing laparoscopic repair of TFH.

Methods: After retrospective review of prospective hernia database at two Hernia centers, patients undergoing laparoscopic TFH repair were identified and analyzed. Main outcome measures included patient demographics, surgical technique, intraoperative data, and post-operative outcomes.

Results: From December 2007 to December 2013, 14 patients underwent laparoscopic repair of a TFH. Eleven patients had chronically incarcerated viscera within the defect. Operative steps included complete reduction of the hernia sac, pre/retroperitoneal dissection to expose the entire lateral edge of a psoas muscle, defect closure with transabdominal sutures, wide mesh overlap, and transabdominal suture fixation with selective use of bone anchors. The mean operative time was 174 min (range 125-230). Mean estimated blood loss was 65 cc. Mean mesh size was 295 cm. There were no peri-operative complications. Mean hospital stay was 3.1 days and all patients returned to full activities by 6 weeks. At a mean follow-up of 35 months, there have been no recurrences.

Conclusion: Laparoscopic approach to TFH is feasible and safe. It is associated with minimal hospital stay and fast functional recovery. The key components of our approach include wide pre/retroperitoneal with defect closure and subsequent wide mesh underlay coverage with fixation to bony structures using anchors/screws. We believe that the laparoscopic approach should safely considered for the majority of patients with TFH.
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http://dx.doi.org/10.1007/s10029-017-1707-7DOI Listing
April 2018

Completed FDA feasibility trial of surgically placed temporary diaphragm pacing electrodes: A promising option to prevent and treat respiratory failure.

Am J Surg 2018 Mar 11;215(3):518-521. Epub 2017 Nov 11.

Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Background: Etiologies contributing to failure to wean from mechanical ventilation (MV) are multiple, resulting in morbid and costly outcomes. Diaphragm pacing (DP) is used in spinal cord injury to replace MV. Temporary DP could be utilized in acute respiratory failure to reduce MV.

Methods: A prospective FDA feasibility trial evaluated temporary DP electrodes implanted in each hemi-diaphragm during a subject's primary procedure. Objectives included: ability to provide ventilation, stability analysis with diaphragm electromyography, and adverse event monitoring.

Results: Twelve patients underwent successful implantation via median sternotomy, laparoscopy or laparotomy. Electrode stimulation exceeded ideal tidal volumes by an average of 37% (0%-95%) confirming ability to prevent atrophy. Daily electromyography confirmed stability of placement and was useful in evaluating hypoventilation. There were no complications and all 48 study electrodes remained intact until complete removal.

Conclusion: This trial demonstrates ease of placement, removal, functionality and safety of temporary DP electrodes which therapeutically decreases diaphragm atrophy.
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http://dx.doi.org/10.1016/j.amjsurg.2017.10.054DOI Listing
March 2018

A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair.

Surg Endosc 2018 03 15;32(3):1525-1532. Epub 2017 Sep 15.

Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA.

Background: The enhanced-view totally extraperitoneal (eTEP) technique has been previously described for Laparoscopic Inguinal Hernia Repair. We present a novel application of the eTEP access technique for the repair of ventral and incisional hernias.

Methods: Retrospective review of consecutive laparoscopic retromuscular hernia repair cases utilizing the eTEP access approach from five hernia centers between August 2015 and October 2016 was conducted. Patient demographics, hernia characteristics, operative details, perioperative complications, and quality of life outcomes utilizing the Carolina's Comfort Scale (CCS) were included in our data analysis.

Results: Seventy-nine patients with mean age of 54.9 years, mean BMI of 31.1 kg/m, and median ASA of 2.0 were included in this analysis. Thirty-four percent of patients had a prior ventral or incisional hernia repair. Average mesh area of 634.4 cm was used for an average defect area of 132.1 cm. Mean operative time, blood loss, and length of hospital stay were 218.9 min, 52.6 mL, and 1.8 days, respectively. There was one conversion to intraperitoneal mesh placement and one conversion to open retromuscular mesh placement. Postoperative complications consisted of seroma (n = 2) and trocar site dehiscence (n = 1). Comparison of mean pre- and postoperative CCS scores found significant improvements in pain (68%, p < 0.007) and movement limitations (87%, p < 0.004) at 6-month follow-up. There were no readmissions within 30 days and one hernia recurrence at mean follow-up of 332 ± 122 days.

Conclusions: Our initial multicenter evaluation of the eTEP access technique for ventral and incisional hernias has found the approach feasible and effective. This novel approach offers flexible port set-up optimal for laparoscopic closure of defects, along with wide mesh coverage in the retromuscular space with minimal transfascial fixation.
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http://dx.doi.org/10.1007/s00464-017-5840-2DOI Listing
March 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

Comparative analysis of perioperative outcomes of robotic versus open transversus abdominis release.

Surg Endosc 2018 Feb 21;32(2):840-845. Epub 2017 Jul 21.

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

Background: Transversus abdominis release (TAR) has evolved as an effective approach to complex abdominal wall reconstructions. Although the role of robotics in hernia surgery is rapidly expanding, the benefits of a robotic approach for abdominal wall reconstruction have not been established well. We aimed to compare the impact of the application of robotics to the TAR procedure on the perioperative outcomes when compared to the open TAR repairs.

Methods: Case-matched comparison of patients undergoing robotic TAR (R-TAR) at two specialized hernia centers to a matched historic cohort of open TAR (O-TAR) patients was performed. Outcome measures included patient demographics, operative details, postoperative complications, and length of hospitalization.

Results: 38 consecutive patients undergoing R-TAR were compared to 76 matched O-TAR. Patient demographics were similar between the groups, but ASA III status was more prevalent in the O-TAR group. The average operative time was significantly longer in the R-TAR group (299 ± 95 vs.. 211 ± 63 min, p < 0.001) and blood loss was significantly lower for the R-TAR group (49 ± 60 vs. 139 ± 149 mL, p < 0.001). Wound morbidity was minimal in the R-TAR, but the rate of surgical site events and surgical site infection was not different between groups. Systemic complications were significantly less frequent in the R-TAR group (0 vs. 17.1%, p = 0.026). The length of hospitalization was significantly reduced in the R-TAR group (1.3 ± 1.3 vs. 6.0 ± 3.4 days, p < 0.001).

Conclusions: In our early experience, robotic TAR was associated with longer operative times. However, we found that the use of robotics was associated with decreased intraoperative blood loss, fewer systemic complications, shorter hospitalizations, and eliminated readmissions. While long-term outcomes and patient selection criteria for robotic TAR repair are under investigations, we advocate selective use of robotics for TAR reconstructions in patients undergoing AWR.
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http://dx.doi.org/10.1007/s00464-017-5752-1DOI Listing
February 2018

Hiatal Hernia Repair: Current Evidence for Use of Absorbable Mesh to Reinforce Hiatal Closure.

Surg Technol Int 2017 Jul;30:182-187

Case Western Reserve School of Medicine, Cleveland Comprehensive Hernia Cente, Cleveland Comprehensive Hernia Center, Department of Surgery, University Hospitals Cleveland Medical Center Cleveland, Ohio.

Introduction: There continues to be debate regarding the best surgical technique for the treatment of paraesophageal hernias. While laparoscopic and robotic approaches are widely employed around the world, the benefits of mesh use to reinforce hiatal closure are still not well established. The goal of this manuscript is to describe the currently available results with biologic and bioabsorbable meshes for treatment of paraesophageal hernias, particularly with reference to the rate of recurrence.

Materials And Methods: A systematic review of the literature was conducted to identify studies describing treatment of hiatal hernias with biologic or bioabsorbable mesh. The available studies were categorized as comparative (when authors compared results with a different patient cohort undergoing suture repair of the hiatus without mesh reinforcement) and non-comparative, and organized by levels of evidence.

Results: We identified two randomized control trials, a long-term follow-up to one of the trials, a prospective case control study, one retrospective case control study, two meta-analyses of the above-mentioned studies, as well as 11 non-comparative studies, which included two prospective, 10 retrospective, and two case series. Most studies involved the use of different biologic meshes, while bioabsorbable mesh use was only described in four of the retrospective studies mentioned. The results are variable, however, most authors found a benefit from hiatal closure reinforcement with mesh.

Conclusions: The available literature lacks definitive evidence to support the use of biologic or bioabsorbable materials to reinforce hiatal closure in the cure of paraesophageal hernias. Further studies are needed to assess newer materials and longer-term effects of existing products.
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July 2017

Is old age a contraindication to elective ventral hernia repair?

Surg Endosc 2017 11 24;31(11):4425-4430. Epub 2017 Mar 24.

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

Background: Ventral hernia repair (VHR) is a frequent problem in the expanding aging population. However, advanced age is often viewed as a contraindication to elective hernia surgery. We aimed to analyze outcomes of VHR in a large cohort of elderly patients. We hypothesized that elective VHR is safe and effective even in patients over 70 years old.

Methods: We conducted a retrospective review of consecutive patients over the age of 70 who underwent VHR at a at a tertiary care hospital. Main outcome measures included postoperative complications and recurrence rate.

Results: Between 2006 and 2015, 263 elderly patients who underwent elective VHR were included. Major comorbidities included diabetes, COPD, and smoking history. The majority of the patients underwent open repairs. Surgical site events occurred in 54 patients (21%). Postoperative complications included 17 venous thromboembolism occurrences, 2 myocardial infarctions, 41 patients who required postoperative critical care, and 1 mortality. Readmission within 90 days postoperatively occurred in 34 patients (13%). At a mean follow-up of 25.6 months, 17 patients in the open group and 6 patients in the laparoscopic group had a recurrence.

Conclusion: We demonstrated that VHR can be performed reasonably safely and effectively even in this potentially risky cohort. The use of laparoscopy might be associated with further reduction in morbidity. Overall, age should not be a contraindication to elective VHR, even in patients over 70 years old.
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http://dx.doi.org/10.1007/s00464-017-5492-2DOI Listing
November 2017

Evaluation of antibiotic pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction.

Surg Endosc 2017 07 31;31(7):2763-2770. Epub 2016 Oct 31.

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

Background: Despite patient risk factors such as diabetes and obesity, contamination during surgery remains a significant cause of infections and subsequent wound morbidity. Pressurized pulse lavage (PPL) has been utilized as a method to reduce bacterial bioburden with promising results in many fields. Although existing methods of lavage have been utilized during abdominal operations, no studies have examined the use of PPL during complex hernia repair.

Methods: Patients undergoing abdominal wall reconstruction (AWR) in clean-contaminated or contaminated fields with antibiotic PPL, from January 2012 to May 2013, were prospectively evaluated. Primary outcome measures studied were conversion of retrorectus space culture from positive to negative after PPL and 30-day surgical site infection (SSI) rate.

Results: A total of 56 patients underwent AWR, with 44 patients (78.6 %) having clean-contaminated fields and 12 patients (21.4 %) having contaminated ones. Twenty-two patients (39.3 %) had positive pre-PPL cultures, 18 of which (81.8 %) converted to negative cultures after PPL. Eleven patients (19.6 %) developed SSIs. Those with persistently positive cultures after PPL had the highest rate of SSI, where two out of four patients (50.0 %) developed an SSI. Contrastingly, only 5 of 18 patients (27.8 %) who converted from a positive to negative culture after PPL developed an SSI.

Conclusion: Our findings demonstrate that antibiotic PPL is an effective method to reduce bacterial bioburden during AWR in clean-contaminated and contaminated fields. While complete conversion and eradication of SSI were not achieved, we believe that PPL may be a useful adjunct to standard operative asepsis in preventing prosthetic contamination during contaminated AWR.
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http://dx.doi.org/10.1007/s00464-016-5283-1DOI Listing
July 2017

Abdominal Closure after TRAM Flap Breast Reconstruction with Transversus Abdominis Muscle Release and Mesh.

Plast Reconstr Surg Glob Open 2016 Sep 21;4(9):e1014. Epub 2016 Sep 21.

Department of Plastic Surgery, National Institute of Medical Sciences and Nutrition, Mexico City, Mexico; and Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.

Breast reconstruction with a pedicled transverse rectus abdominis muscle (TRAM) flap can result in significant abdominal wall donor-site morbidity. Although the pedicled TRAM flap donor area reinforced with mesh results in decreased rates of postoperative abdominal bulging and hernias, the best technique to accomplish that is yet to be elucidated. We present our novel technique of posterior components separation with transversus abdominis muscle release and retromuscular mesh reinforcement for donor-area closure during pedicled TRAM flap breast reconstruction.
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http://dx.doi.org/10.1097/GOX.0000000000001014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055003PMC
September 2016

Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs.

Surgery 2016 10 21;160(4):828-838. Epub 2016 Jul 21.

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

Background: Contaminated operative fields pose significant challenges for surgeons performing ventral hernia repair. Although biologic meshes have been utilized increasingly in these fields, recent evidence suggests that synthetic meshes represent a viable option. We analyzed the outcomes of biologic and synthetic mesh utilized in patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields.

Methods: We conducted a multicenter, retrospective review of patients undergoing open ventral hernia repair in clean-contaminated/contaminated fields using biologic or synthetic mesh. Patient and hernia details were characterized. Primary outcomes included 90-day surgical site event, surgical site infection, and hernia recurrence.

Results: A total of 126 patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields (69 biologic and 57 synthetic meshes) were analyzed. Groups were similar in both patient and hernia characteristics. There were 13 (22.8%) surgical site events in the synthetic cohort compared to 29 (42.0%) in the biologic cohort, P = .024. Similarly, surgical site infections were less frequent in the synthetic group, with 7 (12.3%) vs 22 (31.9%), P = .01. With a mean follow-up of 20 months, there were more recurrences in the biologic group: 15 (26.3%) vs 4 (8.9%) in the synthetic group, P = .039.

Conclusion: The choice of mesh for clean-contaminated/contaminated ventral hernia repair remains debatable. We demonstrated that using synthetic sublay mesh resulted in a significantly lower wound morbidity and more durable outcomes versus a similar cohort of biologic repairs. This is likely secondary to improved bacterial clearance and faster integration of macroporous synthetics. Overall, our findings not only support suitability of synthetic mesh in contaminated settings but also challenge the purported advantage of biologics in clean-contaminated/contaminated ventral hernia repairs.
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http://dx.doi.org/10.1016/j.surg.2016.04.041DOI Listing
October 2016

Evaluation of the Antimicrobial Efficacy of a Novel Rifampin/Minocycline-Coated, Noncrosslinked Porcine Acellular Dermal Matrix Compared With Uncoated Scaffolds for Soft Tissue Repair.

Surg Innov 2016 Oct 28;23(5):442-55. Epub 2016 Jun 28.

University Hospitals Case Medical Center, Cleveland, OH, USA

Background Despite meticulous aseptic technique and systemic antibiotics, bacterial colonization of mesh remains a critical issue in hernia repair. A novel minocycline/rifampin tyrosine-coated, noncrosslinked porcine acellular dermal matrix (XenMatrix AB) was developed to protect the device from microbial colonization for up to 7 days. The objective of this study was to evaluate the in vitro and in vivo antimicrobial efficacy of this device against clinically isolated methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli. Methods XenMatrix AB was compared with 5 existing uncoated soft tissue repair devices using in vitro methods of zone of inhibition (ZOI) and scanning electron microscopy (SEM) at 24 hours following inoculation with MRSA or E coli These devices were also evaluated at 7 days following dorsal implantation and inoculation with MRSA or E coli (60 male New Zealand white rabbits, n = 10 per group) for viable colony-forming units (CFU), abscess formation and histopathologic response, respectively. Results In vitro studies demonstrated a median ZOI of 36 mm for MRSA and 16 mm for E coli for XenMatrix AB, while all uncoated devices showed no inhibition of bacterial growth (0 mm). SEM also demonstrated no visual evidence of MRSA or E coli colonization on the surface of XenMatrix AB compared with colonization of all other uncoated devices. In vivo XenMatrix AB demonstrated complete inhibition of bacterial colonization, no abscess formation, and a reduced inflammatory response compared with uncoated devices. Conclusion We demonstrated that XenMatrix AB possesses potent in vitro and in vivo antimicrobial efficacy against clinically isolated MRSA and E coli compared with uncoated devices.
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http://dx.doi.org/10.1177/1553350616656280DOI Listing
October 2016

Development of a novel murine model for treatment of infected mesh scenarios.

Surg Endosc 2017 02 28;31(2):922-927. Epub 2016 Jun 28.

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

Background: Indications regarding hernia repair after removal of previously infected prostheses remain unclear. Patients may receive staged primary repair or single-stage reconstructions, neither of which may be ideal. Although animal models have simulated contamination by direct inoculation of implants with bacteria, there remains a paucity of literature, which simulates a field following mesh infection and removal. We aimed to develop a murine model to mimic this complex scenario to allow for further testing of various implants.

Methods: Thirty-six female CL57BL/6J mice underwent implantation of a 0.7 × 0.7 cm polyester mesh in the dorsal subcutaneous position. Wounds were closed and inoculated with 100 µL containing 1 × 10 CFU of GFP-labeled MSSA. After 2 weeks, the infected mesh was removed and the cavity was copiously irrigated with saline. Mice were split into four groups: with three groups receiving new polyester, polypropylene, and porcine mesh and remaining as non-mesh controls. Mice were survived for another 2 weeks and underwent necropsy. Gross infection was evaluated at 2 and 4 weeks. Tissue homogenization and direct plating to recover GFP MSSA was completed at 4 weeks.

Results: At 2 weeks, all mice were noted to have gross mesh infection. One animal died due to overwhelming infection and wound breakdown. At 4 weeks, 5/6 (83 %) control mice who did not have a second mesh implantation had full clearance of their wounds. In contrast, 9/10 (90 %) mice with re-implantation of polypropylene were noted to have pus and recovery of GFP MSSA on plating. This was also observed in 100 % of mice with polyester and porcine mesh.

Conclusion: Our novel murine model demonstrates that mesh re-implantation after infected mesh removal results in infection of the newly placed prosthesis, regardless of the material characteristic or type. This model lays foundation for development and investigation of implants for treatment strategies following infected mesh removal.
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http://dx.doi.org/10.1007/s00464-016-5056-xDOI Listing
February 2017

Outcomes of Retromuscular Porcine Biologic Mesh Repairs Using Transversus Abdominis Release Reconstruction.

J Am Coll Surg 2016 09 25;223(3):461-8. Epub 2016 Jun 25.

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

Background: Optimal mesh reinforcement and operative technique for major abdominal wall reconstructions (AWR) remain debatable. Posterior component separation via transversus abdominis release (TAR) allows for wide sublay mesh reinforcement with durable reconstruction, and has been gaining popularity in recent years. Although biologic mesh has been associated with mixed results, outcomes of AWR with bioprosthetics have not been well elucidated to date. We evaluated our outcomes of TAR reconstructions with retromuscular porcine biologic mesh reinforcement.

Study Design: Consecutive patients undergoing AWR using TAR with biologic mesh sublay reinforcement were identified in our prospective databases and analyzed. We characterized patient demographics and perioperative details. Main outcomes measures included wound complications and hernia recurrence.

Results: Between 2007 and 2014, seventy-seven patients (mean age 56 years, mean BMI 35 kg/m(2)) underwent AWR using TAR with biologic mesh. Mean hernia size was 306 ± 128 cm(2) with mean width of 14.3 ± 3.3 cm. The vast majority of patients had grade 3 hernias (92%) and more than half had a history of wound infection (55%). There were 22 (28.6%) surgical site infections consisting of 14 deep, 7 superficial, and 1 organ-space surgical site infections. There were no incidences of chronic mesh infection or explantation. In patients with at least 12 months follow-up (mean duration 28.2 months), there were 8 (12.5%) recurrences.

Conclusions: Complex hernias repaired with TAR and retromuscular porcine biologic mesh reinforcement are associated with a low rate of serious perioperative wound/mesh complications. Additionally, our approach resulted in a fairly low rate of hernia recurrences in this complex cohort of patients. We believe that the TAR approach and retromuscular mesh placement can be beneficial when biologic mesh reinforcement is chosen during complex and/or contaminated abdominal wall reconstructions.
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http://dx.doi.org/10.1016/j.jamcollsurg.2016.06.008DOI Listing
September 2016

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

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

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

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

Efficacy of transversus abdominis plane block with liposomal bupivacaine during open abdominal wall reconstruction.

Am J Surg 2016 Sep 12;212(3):399-405. Epub 2016 Apr 12.

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

Background: Transversus abdominis plane block (TAPb) is an analgesic adjunct used for abdominal surgical procedures. Liposomal bupivacaine (LB) demonstrates prolonged analgesic effects, up to 72 hours. We evaluated the analgesic efficacy of TAPb using LB for patients undergoing open abdominal wall reconstruction (AWR).

Methods: Fifty patients undergoing AWR with TAPb using LB (TAP-group) were compared with a matched historical cohort undergoing AWR without TAPb (control group). Outcome measures included postoperative utilization of morphine equivalents, numerical rating scale pain scores, time to oral narcotics, and length of stay (LOS).

Results: Cohorts were matched demographically. No complications were associated with TAPb or LB. TAP-group evidenced significantly reduced narcotic requirements on operative day (9.5 mg vs 16.5 mg, P = .004), postoperative day (POD) 1 (26.7 mg vs 39.5 mg, P = .01) and POD2 (29.6 mg vs 40.7 mg, P = .047) and pain scores on operative day (5.1 vs 7.0, P <.001), POD1 (4.2 vs 5.5, P = .002), and POD2 (3.9 vs 4.8, P = .04). In addition, TAP-group demonstrated significantly shorter time to oral narcotics (2.7 days vs 4.0 days, P <.001) and median LOS (5.2 days vs 6.8 days, P = .004).

Conclusions: TAPb with LB demonstrated significant reductions in narcotic consumption and improved pain control. TAPb allowed for earlier discontinuation of intravenous narcotics and shorter LOS. Intraoperative TAPb with LB appears to be an effective adjunct for perioperative analgesia in patients undergoing open AWR.
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http://dx.doi.org/10.1016/j.amjsurg.2015.12.026DOI Listing
September 2016

Evaluation of a novel permanent capped helical coil fastener in a porcine model of laparoscopic ventral hernia repair.

Surg Endosc 2016 12 8;30(12):5266-5274. Epub 2016 Apr 8.

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

Background: Existing permanent helical coil fasteners, although commonly employed for mesh fixation during laparoscopic hernia repair, are associated with peritoneal tissue attachment formation and resultant visceral complications. We evaluated attachment formation, fastener engagement, and mesh/tissue integration associated with laparoscopic fixation using a novel permanent capped helical coil fastener (HC-Capped) compared to permanent non-capped helical coil fasteners (HC-Non-Capped) in a porcine model.

Methods: Twelve female pigs underwent bilateral laparoscopic intraperitoneal fixation of Composix™ L/P Mesh (10 × 15 cm oval) with HC-Capped or HC-Non-Capped fasteners. Thirty-two fasteners were used to secure each mesh utilizing a "double-crown" technique. Laparoscopy at 30 days was used to evaluate the presence and area coverage of attachments (Diamond Score) and percentage of engaged fasteners. At 90 days, following necropsy, each mesh was evaluated for the presence, percentage, and tenacity (Butler Score) of attachments and fastener engagement. Samples were biomechanically evaluated to assess tissue integration via T-peel testing.

Results: HC-Capped fasteners demonstrated a significantly lower attachment area score compared to the HC-Non-Capped group at 30 days (0.92 ± 0.26 vs. 2.50 ± 0.29/3.00, p = 0.002) and 90 days (0.60 ± 0.22 vs. 2.08 ± 0.29/3.00, p = 0.004). At 90 days, the HC-Capped group evidenced significantly lower attachment tenacity score (1.00 ± 0.37 vs. 2.75 ± 0.33/4.00, p = 0.013). Furthermore, at 30 and 90 days, a significantly greater percentage of HC-Capped fasteners remained properly engaged (30 days: 99.7 % vs. 86.5 %, p < 0.001 and 90 days: 99.4 % vs. 74.5 %, p = 0.001). T-peel biomechanical testing demonstrated significantly greater mesh/tissue integration for HC-Capped group (2.16 ± 0.24 vs. 1.16 ± 0.29 N/cm, p = 0.038).

Conclusions: In a porcine model, HC-Capped fasteners demonstrated significantly less attachment coverage and tenacity in the early postoperative period. Furthermore, the HC-Capped cohort evidenced significantly greater percentage of properly engaged fasteners and greater mesh/tissue integration. Data suggest that shielding exposed fastener points on the visceral mesh surface with polymer caps may reduce attachment formation and aid in mesh fixation and integration.
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http://dx.doi.org/10.1007/s00464-016-4874-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5112291PMC
December 2016

Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Open Ventral Hernia Repair.

J Am Coll Surg 2016 06 3;222(6):1106-15. Epub 2016 Mar 3.

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

Background: Use of Enhanced Recovery After Surgery (ERAS) pathways have evidenced improved outcomes in several surgical specialties. The effectiveness of ERAS pathways specific to hernia surgery, however, has not yet been investigated. We hypothesized that our ERAS pathway would accelerate functional recovery and shorten hospitalization in patients undergoing open ventral hernia repair (VHR).

Study Design: Consecutive patients undergoing open major VHR using transversus abdominis release and sublay synthetic mesh placement, with use of our ERAS pathway, were compared with a historical cohort before ERAS implementation. Main outcomes measures were time to diet advancement, time to return of bowel function, time to oral narcotics, length of stay (LOS), and 90-day readmissions.

Results: Between January 2014 and January 2015, 100 patients undergoing VHR with ERAS implementation were compared with a historical cohort. The ERAS group demonstrated significantly shorter times to liquid and regular diet: 1.1 vs 2.7 and 3.0 vs 4.8 days, respectively (p < 0.001). Furthermore, ERAS patients demonstrated significantly shorter times to flatus and bowel movement: 3.1 vs 3.9 and 3.6 vs 5.2 days, respectively (p < 0.001). Average LOS was reduced from 6.1 to 4.0 days (p < 0.001), and ERAS patients had significantly fewer 90-day readmissions, 4% vs 16% (p < 0.001).

Conclusions: A comprehensive ERAS pathway for major open VHR was implemented safely. Multimodal perioperative pain management, oral opioid-receptor blockade, and early feeding strategies resulted in accelerated intestinal recovery, shorter hospitalizations, and fewer readmissions. Use of our ERAS pathway appears to result in improved outcomes in patients undergoing open VHR.
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http://dx.doi.org/10.1016/j.jamcollsurg.2016.02.015DOI Listing
June 2016

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