Evaluating patient factors, operative management and postoperative outcomes in trauma laparotomy patients worldwide: a protocol for a global observational multicentre trauma study

INTRODUCTION

Trauma contributes to the greatest loss of disability-adjusted life-years for adolescents and young adults worldwide. In the context of global abdominal trauma, the trauma laparotomy is the most commonly performed operation. Variation likely exists in how these patients are managed and their subsequent outcomes, yet very little global data on the topic currently exists. The objective of the GOAL-Trauma study is to evaluate both patient and injury factors for those undergoing trauma laparotomy, their clinical management and postoperative outcomes.

METHODS

We describe a planned prospective multicentre observational cohort study of patients undergoing trauma laparotomy. We will include patients of all ages who present to hospital with a blunt or penetrating injury and undergo a trauma laparotomy within 5 days of presentation to the treating centre. The study will collect system, patient, process and outcome data, following patients up until 30 days postoperatively (or until discharge or death, whichever is first). Our sample size calculation suggests we will need to recruit 552 patients from approximately 150 recruiting centres.

DISCUSSION

The GOAL-Trauma study will provide a global snapshot of the current management and outcomes for patients undergoing a trauma laparotomy. It will also provide insight into the variation seen in the time delays for receiving care, the disease and patient factors present, and patient outcomes. For current standards of trauma care to be improved worldwide, a greater understanding of the current state of trauma laparotomy care is paramount if appropriate interventions and targets are to be identified and implemented.

The 6:1 short stitch SL-WL-ratio: short term closure results of transverse and midline incisions in elective and emergency operations

AIM

To analyze laparotomy closure quality (suture/wound length ratio; SL/WL) and short term complications (surgical site occurrence; SSO) of conventional midline and transverse abdominal incisions in elective and emergency laparotomies with a longterm, absorbent, elastic suture material.

METHOD

Prospective, monocentric, non-randomized, controlled cohort study on short stitches with a longterm resorbable, elastic suture (poly-4-hydroxybutyrate, [p-4OHB]) aiming at a 6:1 SL/WL-ratio in midline and transverse, primary and secondary laparotomies for elective and emergency surgeries.

RESULTS

We included 351 patients (♂: 208; ♀: 143) with midline (n = 194), transverse (n = 103), and a combined midline/transverse L-shaped (n = 54) incisions. There was no quality difference in short stitches between elective (n = 296) and emergency (n = 55) operations. Average SL/WL-ratio was significantly higher for midline than transverse incisions (6.62 ± 2.5 vs 4.3 ± 1.51, p < 0.001). Results in the first 150 patients showed a reduced SL/WL-ratio to the following 200 suture closures (SL/WL-ratio: 5.64 ± 2.5 vs 6.1 ± 2.3; p < 0.001). SL/WL-ratio varied insignificantly among the six surgeons participating while results were steadily improving over time. Clinically, superficial surgical site infections (SSI, CDC-A1/2) were encountered in 8%, while 4,3% were related to intraabdominal complications (CDC-A3). An abdominal wall dehiscence (AWD) occurred in 22/351 patients (6,3%)-twice as common in emergency than elective surgery (12,7 vs 5,1%)-necessitating an abdominal revision in 86,3% of cases.

CONCLUSION

We could show that a short stitch 6:1 SL/WL-ratio with a 2-0 single, ultra-long term, absorbent, elastic suture material can be performed in only 43% of cases (85% > 4:1 SL/WL-ratio), significantly better in midline than transverse incisions. Transverse incisions should preferably be closed in two layers to achieve a sufficient SL/WL-ratio equivalent to the median incision.

CLINICAL TRIALS

GOV IDENTIFIER

NCT01938222.

Damage Control Laparotomy and Management of the Open Abdomen

Management of the open abdomen has been used for decades by general surgeons. Techniques have evolved over those decades to improve control of infection, fluid loss, and improve the ability to close the abdomen to avoid hernia formation. The authors explore the history, indications, and techniques of open abdomen management in multiple settings. The most important considerations in open abdomen management include the reason for leaving the abdomen open, prevention and mitigation of ongoing organ dysfunction, and eventual plans for abdominal closure.

Small bites versus large bites during fascial closure of midline laparotomies: a systematic review and meta-analysis

PURPOSE

Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing up to 60% at 3-5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH.

METHODS

We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%.

RESULTS

1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39-0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53-0.86; P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min; 95% CI 3.21-6.35; P < 0.001). No differences were seen regarding fascial dehiscence.

CONCLUSION

SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

Perioperative and reproductive outcomes' comparison of mini-laparotomy and laparoscopic myomectomy in the management of uterine leiomyomas: a systematic review

OBJECTIVE

To evaluate and compare mini-laparotomy (MLPT) with laparoscopic (LPS) myomectomy perioperative and reproductive outcomes.

METHODS

We systematically searched for related articles in the MEDLINE, Embase, Web of Science and the Cochrane library databases. Nine studies (4 randomized, 3 retrospective, 1 prospective and 1 case-control study) which involved 1723 patients met the inclusion criteria and were considered eligible for inclusion.

RESULTS

Demographic characteristics were similar between the two groups. LPS was associated with shorter hospital stay (p = 0.04), lower blood loss (p < 0.00001), shorter duration of median ileus (p < 0.00001) and fewer episodes of postoperative fever (p = 0.04). None of the reproductive factors examined (pregnancy rate, preterm delivery, vaginal delivery and delivery with caesarean section) in women diagnosed with unexplained infertility and/or symptomatic leiomyomas reached statistical significance although the results represent a small size effect.

CONCLUSION

Our analysis demonstrated that LPS seems to be an alternative, safe and reliable surgical procedure for uterine leiomyoma treatment and in everyday practice seems to offer improved outcomes-regarding at least the perioperative period-over MLPT.

Effect of 3D laparoscopy versus traditional laparotomy on serum tumor markers and coagulation function in patients with early-stage endometrial cancer

OBJECTIVES

To investigate the impact of Three-Dimensional (3D) laparoscopy compared to traditional laparotomy on serum tumor markers and coagulation function in patients diagnosed with early-stage Endometrial Cancer (EC).

METHOD

The authors retrospectively analyzed the clinical data of 75 patients diagnosed with early-stage EC and categorized them into two groups based on the surgical techniques employed. The 3D group consisted of 36 patients who underwent 3D laparoscopic surgery, while the Laparotomy group comprised 39 patients who underwent traditional laparotomy. The authors then compared the alterations in serum tumor markers and coagulation function between the two groups.

RESULTS

Postoperatively, serum levels of CA125, CA199, and HE4 were notably reduced in both groups on the third day, with the levels being more diminished in the 3D group than in the Laparotomy Group (p < 0.05). Conversely, FIB levels escalated significantly in both groups on the third-day post-surgery, with a more pronounced increase in the 3D group. Additionally, PT and APTT durations were reduced and were more so in the 3D group than in the laparotomy group (p < 0.05).

CONCLUSIONS

When juxtaposed with traditional laparotomy, 3D laparoscopic surgery for early-stage EC appears to be more efficacious, characterized by reduced complications, and expedited recovery. It can effectively mitigate serum tumor marker levels, attenuate the inflammatory response and damage to immune function, foster urinary function recovery, and enhance the quality of life. However, it exerts a more significant influence on the patient's coagulation parameters, necessitating meticulous prevention and treatment strategies for thromboembolic events in clinical settings.

Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study

BACKGROUND

Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure.

METHODS

We conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition.

RESULTS

We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 ​% vs. 11.9 ​%; p ​= ​0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 ​% vs. 4.4 ​%; p ​= ​0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group.

CONCLUSION

The rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.

Complete Resection of Necrotic Bowel Improves Survival in NEC Without Compromising Enteral Autonomy

AIMS

Controversy persists regarding operative strategy for necrotising enterocolitis (NEC). Some surgeons advocate resecting all necrotic bowel, whilst others defunction with a stoma, leaving diseased bowel in situ to preserve bowel length. We reviewed our institutional experience of both approaches.

METHODS

Neonates undergoing laparotomy for NEC May 2015-2019 were identified. Data extracted from electronic records included: demographics, neonatal Sequential Organ Failure Assessment (nSOFA) score at surgery, operative findings, and procedure performed. Neonates were assigned to two groups according to operative strategy: complete resection of necrotic bowel (CR) or necrotic bowel left in situ (LIS). Primary outcome was survival, and secondary outcome was enteral autonomy. Outcomes were compared between groups.

RESULTS

Fifty neonates were identified. Six were excluded: 4 with NEC totalis and 2 with no visible necrosis or histological confirmation of NEC. Of the 44 remaining neonates, 27 were in the CR group and 17 in the LIS group. 32 neonates survived to discharge (73%). On univariate analysis, survival was associated with lower nSOFA score (P = 0.003), complete resection of necrotic bowel (OR 9.0, 95% CI [1.94-41.65]), and being born outside the surgical centre (OR 5.11 [1.23-21.28]). On Cox regression multivariate analysis, complete resection was still strongly associated with survival (OR 4.87 [1.51-15.70]). 28 of the 32 survivors (88%) achieved enteral autonomy. There was no association between operative approach and enteral autonomy (P = 0.373), or time to achieve this.

CONCLUSION

Complete resection of necrotic bowel during surgery for NEC significantly improves likelihood of surviving without negatively impacting remaining bowel function.

LEVEL OF EVIDENCE

III.

Paradigms in trauma laparoscopy for anterior abdominal stab wounds: A scoping review

INTRODUCTION

Anterior abdominal stab wounds (AASW) are a heterogeneous presentation with evolving management over time and heterogenous practice between centres. The aim of this scoping review was to identify, characterise and classify paradigms for trauma laparoscopies for AASW.

METHODOLOGY

Studies were screened from Embase, Medline, Scopus, Cochrane Library and Web of Science from 1 January 1947 until 1 January 2023. Extracted data included indications for trauma laparoscopies vs laparotomies, and criteria for conversion to an open procedure.

RESULTS

Of 72 included studies, 35 (48.6 %) were published in the United States, with an increasing number from South Africa since 2014. Screening tests to determine an indication for surgery included local wound exploration, computed tomography, and serial clinical examination. Two studies proposed no absolute contraindications to laparoscopy, whereas most papers supported trauma laparoscopies over laparotomies in hemodynamically stable patients with positive or equivocal screening tests. However, clinical decision trees were used inconsistently both between and within many hospital centres. Triggers for conversion to laparotomy were diverse. Older studies typically reported conversion if peritoneal breach was identified. More recent studies reported advances in technical skills and technology allowed attempt at laparoscopic repair for organ and/or vascular injury.

CONCLUSION

This review emphasises that there are many different paradigms of practice for AASW laparoscopy, which are evolving over time. Significant heterogeneity of these studies highlights that meta-analysis of outcomes for trauma laparoscopy is not appropriate unless the included studies report homogenous treatment paradigms and patient cohorts. The decision to perform a trauma laparoscopy should be based on surgeon/hospital experience, patient factors, and resource availability.

C-section technique vs minilaparotomy after minimally invasive uterine surgery: a retrospective cohort study

PURPOSE

Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical interventions such as hysterectomy. In laparotomy, the issue of extracting the fibroid from the cavity does not arise. However, in laparoscopy and robotic surgery, this becomes a challenge. The aim of the present study was to determine the optimal surgical approach for fibroid extraction following laparoscopic or robotic myomectomy in terms of postoperative pain, extraction time, overall surgical time, scar size, and patient satisfaction.

METHODS

A total of 51 patients met the inclusion criteria and were considered in our analysis: 33 patients who had undergone the "ExCITE technique" (Group A), and 18 patients a minilaparotomy procedure (Group B), after either simple myomectomy, multiple myomectomy, supracervical hysterectomy, or total hysterectomy. The diagnosis of myoma was histologically confirmed in all cases.

RESULTS

Regarding the postoperative pain evaluation, at 6 h, patients reported 4 [3-4] vs 6 [5.3-7] on the VAS in Group A and B, as well as at 12 h, 2 [0-2] vs 3.5 [2.3-4] in Group A and B, respectively: both differences were statistically significant (p < 0.001). No statistically significant difference at 24 h from surgery was found. All patients in Group A were satisfied with the ExCITE technique, while in Group B only 67% of them. The length of the hospital stay was significantly shorter in Group A as compared to Group B (p = 0.007). In terms of the operative time for the extraction of the surgical specimen, overall operative time, and the scar size after the surgery, there was a statistically significant difference for those in Group A.

CONCLUSION

The ExCITE technique does not require specific training and allows the surgeon to offer a minimally invasive surgical option for patients, with also an aesthetic result. It is a safe and standardized approach that ensures tissue extraction without the need for mechanical morcellation.

Expect the unexpected: bezoar-caused gastric perforation in the 19-year-old patient, after traffic accident

A 19-year-old female involved in a traffic accident presented to the Emergency Room (ER) with no trauma-related symptoms but a palpable mass in the epigastrium. Imaging revealed a massive trichobezoar causing gastric perforation. Urgent laparotomy was performed, and a 1.5-kilogram bezoar was removed, along with repairing coexisting gastric ulcers. The patient had a history of trichophagia, suggesting a psychiatric association. This case highlights the potential of trichobezoars to cause gastric perforation, even in patients admitted for unrelated reasons. CT-scan proves effective in diagnosing such cases. While a traffic accident might be a plausible cause, the presence of a bezoar can elevate the risk of complications. Psychiatric evaluation is recommended when trichophagia is identified. The study underscores the need for vigilance in unexpected scenarios, demonstrating the importance of multidisciplinary approaches in managing such cases.

Role of laparoscopy in management of patients with anterior abdominal stab wounds

BACKGROUND

In this retrospective cohort study, we assessed the utility of laparoscopic surgery for diagnostic and therapeutic purposes in patients with anterior abdominal stab wounds (AASWs). We also investigated patient characteristics that might suggest a greater suitability of laparoscopic interventions.

METHODS

Over a 25-year span, we analyzed AASW patients who had operations, categorizing them based on the presence of significant intra-abdominal injuries and whether they received laparoscopic surgery or laparotomy. We compared variables such as preoperative conditions, surgical details, and postoperative outcomes. We further evaluated the criteria indicating the necessity of direct laparotomies and traits linked to overlooked injuries in laparoscopic surgeries.

RESULTS

Of 142 AASWs surgical patients, laparoscopic surgery was conducted on 89 (62.7%) patients. Only 2 (2.2%) had overlooked injuries after the procedure. Among patients without significant injuries, those receiving laparoscopic surgery had less blood loss than those receiving laparotomy (30.0 vs. 150.0 ml, p = 0.004). Patients who underwent laparoscopic surgery also had shorter hospital stays (significant injuries: 6.0 vs. 11.0 days, p < 0.001; no significant injuries: 5.0 vs. 6.5 days, p = 0.014). Surgical complications and overlooked injury rates were comparable between both surgical methods. Bowel evisceration correlated with higher laparotomy odds (odds ratio = 16.224, p < 0.001), while omental evisceration did not (p = 0.107).

CONCLUSIONS

Laparoscopy is a safe and effective method for patients with AASWs, fulfilling both diagnostic and therapeutic needs. For stable AASW patients, laparoscopy could be the preferred method, reducing superfluous nontherapeutic laparotomies.

Decompressive Laparotomy for Veno-Venous Extracorporeal Membrane Oxygenation Failure due to Intra-Abdominal Hypertension in Critically Ill COVID-19 Patient

The use of extracorporeal membrane oxygenation (ECMO) has increased over the course of the SARS-CoV-2 pandemic. Intra-abdominal hypertension resulting in abdominal compartment syndrome (ACS) during ECMO support is a rare but life-threatening complication, with previous case series describing mortality rates of 44%-100%. Bleeding complications, linked to both patient-related and device-related factors, also characterize prolonged ECMO support and have been reported in up to 60% of ECMO patients. We hereby describe a critically ill COVID-19 patient who underwent emergent bed-side decompressive laparotomy for acute ECMO failure related to the development of ACS. The discussion is focused on surgical considerations including the delicate balance between anticoagulation and thrombosis, as anticoagulation-free ECMO support may be required due to hemorrhagic complications.

THE INFLUENCE OF THE ONCOLOGICAL PROCESS ON THE MECHANICAL STRENGTH OF THE POSTOPERATIVE SCAR OF THE LAPAROTOMY WOUND

The aim - to examine mechanical strength of the postoperative scar of the laparotomy wound depending on the stage of oncological process at various terms after surgery performed. Examined 194 physical bodies of deceased persons, according to the protocols of the pathological examination (in which the card numbers of the patients are indicated) and who underwent surgical intervention on the organs of the abdominal cavity. Summarizing the results of the study, it should be noted that on the 1st day after surgery, the mechanical strength of the postoperative scar of the laparotomy wound does not depend on the stage of the oncological process and the type of surgery performed, which proves that there is no significant difference in the above-mentioned study groups. Reduced mechanical strength of the postoperative scar was found in the main group on the 1st day of the study. Similar to the 1st day situation is seen on the 2nd and 3rd days of the research. This confirms the morphological experimental studies carried out earlier, which indicate that malignant neoplasm in the body considerably inhibits and slows down the processes of maturation of the granulation tissue. The study once again proves the negative influence of the presence of a malignant neoplasm on the mechanical strength of the postoperative scar of a laparotomy wound. Oncological process negatively affects the mechanical strength of the postoperative scar. Mechanical strength of the postoperative scar of the laparotomy wound is directly proportional to the stage of oncological process and the size of the tumor removed.

Surgical techniques for mini-laparotomy myomectomy

CONTEXT AND BACKGROUND

The prevalence of uterine fibroids is estimated to be approximately 80%. Fibroids can be associated with abnormal uterine bleeding, pressure symptoms, and infertility. Given this high prevalence, approximately 30,000 myomectomies are performed in the United States per year. Minimally invasive approaches are preferred, if feasible. The minimally invasive techniques include laparoscopic, robot-assisted, hysteroscopic, and mini-laparotomy.

OBJECTIVE

To discuss the multiple techniques for optimizing the use of mini-laparotomy in minimally invasive myomectomy.

DESIGN

We use intraoperative surgical video to demonstrate techniques that optimize the use of the mini-laparotomy for myomectomy.

SETTING

Cleveland Clinic.

PATIENT(S)

Patient's undergoing fertility preserving, minimally invasive myomectomy at the Cleveland Clinic. The patient(s) included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites.

INTERVENTION(S)

After the surgeon has selected to proceed with mini-laparotomy myomectomy, different techniques can be employed to optimize management. We demonstrate and discuss these techniques to ensure that surgeons have a set of tools to tackle a fibroid uterus. These techniques include direct palpation of the fibroids, use of a uterine manipulator to visualize the endometrial cavity, use of the uterine manipulator to aid in repair of the cavity if entered, suturing technique that avoids the endometrial cavity and therefore limits foreign body exposure and decreases intrauterine adhesion formation, utilization of barbed suture in a layered fashion, in-situ debulking to avoid injury to fallopian tubes and other critical uterine structures, easy identification of the optimal enucleation plane, use of single hysterotomy for multiple fibroids, visualization of the "Tortuga" sign, and evaluation of the abdominal cavity using the mini-laparotomy site as a port site. To limit postoperative adhesion formation, the investigators place cellulose-based adhesion barriers with peritoneum closure. Although the need for prolonged postoperative observation can be made on a case-by-case basis, we consider this as an outpatient surgery and anticipate same-day discharge for our patients.

MAIN OUTCOME MEASURE(S)

In this video, we perform a mini-laparotomy myomectomy optimally and describe the techniques employed.

RESULT(S)

Specific techniques employed in mini-laparotomy myomectomy make the case safe, effective, and can lead to same-day discharge.

CONCLUSION(S)

Mini-laparotomy myomectomy is a technique used to perform minimally invasive myomectomy. Following the discussed steps, surgeons can be more confident in performing this method of myomectomy.

Longitudinal analysis of long-term outcomes of colorectal cancer after laparotomy and laparoscopic surgery: The Shizuoka study

BACKGROUND

Long-term cancer prognosis after initial surgical procedures is an unlikely endpoint for clinical trials. Medical claim databases may aid in addressing this issue regardless of limited information on disease and patient background. However, the long-term prognosis (especially regarding long-term care needs) following surgical procedures remains unclear. This study aimed to assess whether long-term outcomes, such as the exacerbation of long-term care needs and mortality, differ with surgical methods.

METHODS

Using a longitudinal study with linkage between medical claim and long-term care database, patients with primary colorectal cancer who underwent initial colonoscopies were identified through anonymized data in Japan (Shizuoka Kokuho Database, 2012-2018). Odds ratios (ORs) for long-term outcomes (long-term care needs and all-cause mortality during a 6.5-year follow-up period) were analyzed using logistic regression to compare laparoscopy and endoscopic surgery to laparotomy.

RESULTS

Overall, 3,744 primary colorectal cancer cases (822 laparotomies, 705 laparoscopies, and 2,217 endoscopic surgeries) were included. Compared to the laparotomy group, the crude OR for exacerbation of long-term care needs in the laparoscopic surgery group was 0.376 (95% confidence interval, 0.227, 0.624), while the OR for all-cause mortality was 0.22 (0.329, 0.532).

CONCLUSION

This is the first study to analyze long-term prognosis after surgery for patients with colorectal cancer to combine medical and long-term needs data. As the national health insurance claim database rarely includes information on cancer stage and comorbidities, better prognosis on endoscopic surgery may need careful interpretation. Therefore, laparoscopy has superior outcomes in terms of long-term care needs and mortality compared to those of laparotomy.

Minimally invasive surgery versus laparotomy of nonmetastatic pT4a colorectal cancer: a propensity score analysis

AIM

The aim was to compare short-term and long-term oncological outcomes between minimally invasive surgery (MIS group) and laparotomy (lap group) in nonmetastatic pT4a colorectal cancer (CRC).

MATERIALS AND METHODS

The study retrospectively analyzed the outcomes of 634 patients treated with radical operation from January 2015 to December 2021 for nonmetastatic pT4a CRC, with propensity score matching.

RESULTS

The conversion rate from the MIS group to laparotomy is 3.5%. Intraoperative blood loss, time to first anal exhaust, defecation and drainage tube removal, and complication rate were significantly less in the MIS group. After 5 years, the outcomes of the MIS group were no inferior to laparotomy outcomes [overall survival (OS): 72.7 vs. 77.8%, P =0.285; disease-free survival (DFS): 72.2 vs. 75.0%, P =0.599]. And multivariate analysis showed that age greater than or equal to 60 years old, lymph node metastasis and the carcinoembryonic antigen levels were independent variables for OS, while lymph node metastasis and CA125 levels were independent variables for DFS. The results of the graph show the relationship between the sum of scores of sex, age, complications, BMI, carcinoembryonic antigen, age, CA125, tumor site, N stage and tumor length diameter and 1-year, 3-year, and 5-year mortality and DFS of patients. Among them, tumor length diameter and N stage are significantly correlated with long-term survival and disease-free of patients.

CONCLUSION

MIS is safe and feasible for nonmetastatic pT4a CRC, with the added benefit of accelerated postoperative recovery. In oncology, MIS did not affect OS and DFS.

Small bite versus large bite stitching technique for midline laparotomy wound closure: A systematic review and meta-analysis

Mass closure with a continuous suture using large bite stitching technique has been widely accepted for midline laparotomy wound closures. However, emerging evidence suggests the use of small bite technique to reduce rates of incisional ventral hernia, surgical site infection (SSI) and burst abdomen. This meta-analysis aims to compare small versus large bite stitching techniques to assess complication rates in midline laparotomy wound closures. A comprehensive multi-database search (OVID EBM Reviews, OVID Medline, EMBASE, Scopus) was conducted from database inception to 11th October 2021 according to PRISMA guidelines. We included studies comparing post-operative complication rates of small bite versus large bite stitching techniques for midline laparotomy wound closure. Extracted data was pooled for meta-analysis evaluating rates of incisional ventral hernia, SSI and burst abdomen. We included five randomized controlled trials (RCT) in the meta-analysis and three prospective cohort studies for qualitative analysis. A total of 1977 participants composed of 961 small bite and 1016 large bite technique patients were included from the five RCTs. There was a significant reduction in the rates of incisional ventral hernia and SSI with the small bite stitch technique with odds ratios (OR) of 0.39 (95% CI [0.21-0.71]) and 0.68 (95% CI [0.51-0.91]) respectively, and a trend in favour of reduced incidence of burst abdomen with OR of 0.60 (95% CI [0.15-2.48]). Small bite stitch technique in midline laparotomy wound closure may be superior over conventional mass closure using the large bite stitch technique, with statistically significant lower rates of incisional ventral hernia and SSI.

Continuous versus interrupted abdominal wall closure after emergency midline laparotomy: CONTINT: a randomized controlled trial [NCT00544583]

BACKGROUND

High-level evidence regarding the technique of abdominal wall closure for patients undergoing emergency midline laparotomy is sparse. Therefore, we conducted a randomized controlled trial (RCT) to evaluate the efficacy and safety of two commonly applied abdominal wall closure strategies after primary emergency midline laparotomy.

METHODS/DESIGN

CONTINT was a multi-center pragmatic open-label exploratory randomized controlled parallel trial. Two different abdominal wall closure strategies in patients undergoing primary midline laparotomy for an emergency surgical intervention with a suspected septic focus in the abdominal cavity were compared: the continuous, all-layer suture and the interrupted suture technique. The primary composite endpoint was burst abdomen within 30 days after surgery or incisional hernia within 12 months. As reliable data on this composite primary endpoint were not available for patients undergoing emergency surgery, it was planned to initially recruit 80 patients and conduct an interim analysis after these had completed the 12 months follow-up.

RESULTS

From August 31, 2009, to June 28, 2012, 124 patients were randomized of whom 119 underwent surgery and were analyzed according to the intention-to-treat (ITT) principal. The primary composite endpoint did not differ between the continuous suture (C: 27.1%) and the interrupted suture group (I: 30.0%). None of the individual components of the primary endpoint (reoperation due to burst abdomen after 30 days (C: 13.5%, I: 15.1%) and reoperation due to incisional hernia (C: 3.0%, I:11.1%)) differed between groups. Time needed for fascial closure was longer in the interrupted suture group (C: 12.8 ± 4.5 min, I: 17.4 ± 6.1 min). BMI was associated with burst abdomen during the first 30 days with an OR of 1.17 (95% CI 1.04-1.32).

CONCLUSION

This RCT showed no difference between continuous suture with slowly absorbable suture versus interrupted rapidly absorbable sutures after primary emergency midline laparotomy in rates of postoperative burst abdomen and incisional hernia after one year. However, the trial was stopped after the interim analysis due to futility as there was no chance to show superiority of one suture technique.

Revisiting abdominal closure in mesenteric ischemia: is there an association with outcome?

PURPOSE

Current guidelines advocate liberal use of delayed abdominal closure in patients with acute mesenteric ischemia (AMI) undergoing laparotomy. Few studies have systematically examined this practice. The goal of this study was to evaluate the effect of delayed abdominal closure on postoperative morbidity and mortality in patients with AMI.

METHODS

We performed a retrospective cohort study of the ACS-NSQIP 2013-2017 registry. We included patients with a diagnosis of AMI undergoing emergency laparotomy. Patients were divided into two groups based on the type of abdominal closure: (1) delayed fascial closure (DFC) when no layers of the abdominal wall were closed and (2) immediate fascial closure (IFC) if deep layers or all layers of the abdominal wall were closed. Propensity score matching was performed based on comorbidities, pre-operative, and operative characteristics. Univariable analysis was performed on the matched sample.

RESULTS

The propensity-matched cohort consisted of 1520 patients equally divided into the DFC and IFC groups. The median (IQR) age was 68 (59-77), and 836 (55.0%) were female. Compared to IFC, the DFC group showed increased in-hospital mortality (38.9% vs. 31.6%, p = 0.002), 30-day mortality (42.4% vs. 36.3%, p = 0.012), and increased risk of respiratory failure (59.5% vs. 31.2%, p < 0.001).

CONCLUSIONS

The delayed fascial closure technique was associated with increased mortality compared to immediate fascial closure. These findings do not support the blanket incorporation of delayed closure in mesenteric ischemia care or its previously advocated liberal use.

Patient-specific computational simulations of wound healing following midline laparotomy closure

In the current study, we developed a new computational methodology to simulate wound healing in soft tissues. We assumed that the injured tissue recovers partially its mechanical strength and stiffness by gradually increasing the volume fraction of collagen fibers. Following the principles of the constrained mixture theory, we assumed that new collagen fibers are deposited at homeostatic tension while the already existing tissue undergoes a permanent deformation due to the effects of remodeling. The model was implemented in the finite-element software Abaqus® through a VUMAT subroutine and applied to a complex and realistic case: simulating wound healing following midline laparotomy closure. The incidence of incisional hernia is still quite significant clinically, and our goal was to investigate different conditions hampering the success of these procedures. We simulated wound healing over periods of 6 months on a patient-specific geometry. One of the outcomes of the finite-element simulations was the width of the wound tissue, which was found to be clinically correlated with the development of incisional hernia after midline laparotomy closure. We studied the impact of different suturing modalities and the effects of situations inducing increased intra-abdominal pressure or its intermittent variations such as coughing. Eventually, the results showed that the main risks of developing an incisional hernia mostly depend on the elastic strains reached in the wound tissue after degradation of the suturing wires. Despite the need for clinical validation, these results are promising for establishing a digital twin of wound healing in midline laparotomy incision.

Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy?

BACKGROUND

Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy.

METHODS

The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed.

RESULTS

Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh.

CONCLUSION

The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.

An overview of the current debate between using minimally invasive surgery versus laparotomy for interval cytoreductive surgery in epithelial ovarian cancer

The standard of care for treatment of advanced-stage epithelial ovarian cancer is primarily surgery followed by platinum-based chemotherapy, with the operative goal to achieve complete gross resection. Cytoreductive surgeries for epithelial ovarian cancer historically were performed via open laparotomy; however, as minimally invasive techniques became more widely accepted within gynecologic oncology, interest in employing this approach in the setting of cytoreductive surgery for epithelial ovarian cancer has grown. The purpose of this review was to examine the current debate between the use of minimally invasive surgery versus laparotomy as an approach to interval cytoreductive surgery in advanced epithelial ovarian cancer. While numerous retrospective and feasibility studies have found comparable outcomes with respect to complete gross residual disease, progression-free survival, and overall survival between minimally invasive and laparotomy approaches to interval cytoreductive surgery for epithelial ovarian cancer, methodological challenges limit the utility of these data. Given potential risks of underestimating disease burden and failing to achieve complete resection using a minimally invasive approach, further rigorous studies are needed to evaluate the safety and efficacy of minimally invasive surgery in this setting and to better define the subset of patients who would receive the greatest benefit from a minimally invasive approach.

Negative laparotomy rates and outcomes following blunt traumatic injury in the United States

INTRODUCTION

Exploratory laparotomy remains the mainstay of treatment following blunt abdominal trauma. However, the decision to operate can be difficult in hemodynamically stable patients with unreliable physical exams or equivocal imaging findings. The risk of a negative laparotomy and the subsequent complications must be weighed against the potential morbidity and mortality of a missed abdominal injury. Our study aims to evaluate trends and the effect of negative laparotomies on morbidity and mortality in adults with blunt traumatic injuries in the United States.

METHODS

We reviewed the National Trauma Data Bank (2007-2019) for adults with blunt traumatic injuries who underwent an exploratory laparotomy. Positive or negative laparotomy of abdominal injury was compared. We performed bivariate analysis and a modified Poisson regression to estimate the effect of negative laparotomy on mortality. A sub-analysis of patients who underwent computed tomography (CT) of the abdomen and pelvis was performed.

RESULTS

92,800 patients met the inclusion criteria of the primary analysis. Negative laparotomy rates were 12.0% in this population, down-trending throughout the study. Negative laparotomy patients had a significantly higher crude mortality (31.1% vs. 20.5%, p < 0.001), despite lower injury severity scores (20 (10-29) vs. 25 (16-35), p < 0.001) than positive laparotomy patients. Patients that underwent negative laparotomy had a 33% higher risk for mortality (RR1.33, 95% CI 1.28-1.37, P < 0.001) than positive laparotomy patients after adjusting for pertinent covariates. Patients that underwent CT abdomen/pelvis imaging (n = 45,654) had a lower rate of negative laparotomy (11.1%) and decreased difference in crude mortality (22.6% vs. 14.1%, p < 0.001) compared to positive laparotomy patients. However, the relative risk for mortality remained high at 37% (RR 1.37, 95% CI 1.29 - 1.46, p < 0.001) for this sub-cohort.

CONCLUSION

Negative laparotomy rates in adults with blunt traumatic injuries are trending down in the United States but remains substantial and may show improvement with increased use of diagnostic imaging. Negative laparotomy has a relative risk for mortality of 33% despite lower injury severity. Thus, surgical exploration in this population should be thoughtfully undertaken with appropriate evaluation via physical exam and diagnostic imaging to prevent unnecessary morbidity and mortality.

Abdominal wound dehiscence and incisional hernia prevention in midline laparotomy: a systematic review and network meta-analysis

BACKGROUND

Incisional hernia (IH) is the main complication after laparotomy. In an attempt to reduce this complication, mesh techniques and studies in which the closure technique is modified have been proposed. Both types are characterized by comparison with the closure described as standard or conventional: 1 × 1, mass, and continuous closure. For this study, modified closure techniques (MCTs) were considered as those techniques in which an extra suture is placed (reinforced tension line (RTL), retention), the closure point is modified in distance (small bites) or shape (CLDC, Smead Jones, interrupted, Cardiff point) and which aim to reduce these complications. The objective of this network meta-analysis (NMA) was to evaluate the effectiveness of MCTs for reducing the incidence of IH and abdominal wound dehiscence (AWD) to provide objective support for their recommendation.

METHODS

An NMA was performed according to the PRISMA-NMA guidelines. The primary objective was to determine the incidence of IH and AWD, and the secondary objective was to determine the incidence of postoperative complications. Only published clinical trials were included. The risk of bias was analyzed, and the random-effects model was used to determine statistical significance.

RESULTS

Twelve studies comparing 3540 patients were included. The incidence of HI was lower in RTL, retention suture, and small bites, these techniques showed statistical differences with pooled ORs (95% CI) of 0.28 (0.09-0.83), 0.28 (0.13-0.62), and 0.44 (0.31-0.62), respectively. Associated complications, including hematoma, seroma, and postoperative pain, could not be analyzed; however, MCTs did not increase the risk of surgical site infection.

CONCLUSION

Small bites, RTL, and retention sutures decreased the prevalence of IH. RTL and retention suture decreased the prevalence of AWD. RTL was the best technique as it reduced both complications (IH and AWD) and had the best SUCRA and P-scores, and the number needed to treat (NNT) for net effect was 3.

REGISTRATION

This study was prospectively registered in the PROSPERO database under registration number CRD42021231107.

Prophylactic onlay mesh placement techniques for optimal abdominal wall closure: randomized controlled trial in an ex vivo biomechanical model

BACKGROUND

Incisional hernias occur after up to 40 per cent of laparotomies. Recent RCTs have demonstrated the role of prophylactic mesh placement in reducing the risk of developing an incisional hernia. An onlay approach is relatively straightforward; however, a variety of techniques have been described for mesh fixation. The biomechanical properties have not been interrogated extensively to date.

METHODS

This ex vivo randomized controlled trial using porcine abdominal wall investigated the biomechanical properties of three techniques for prophylactic onlay mesh placement at laparotomy closure. A classical onlay, anchoring onlay, and novel bifid onlay approach were compared with small-bite primary closure. A biomechanical abdominal wall model and ball burst test were used to assess transverse stretch, bursting force, and loading characteristics.

RESULTS

Mesh placement took an additional 7-15 min compared with standard primary closure. All techniques performed similarly, with no clearly superior approach. The minimum burst force was 493 N, and the maximum 1053 N. The classical approach had the highest mean burst force (mean(s.d.) 853(152) N). Failure patterns fell into either suture-line or tissue failures. Classical and anchoring techniques provided a second line of defence in the event of primary suture failure, whereas the bifid method demonstrated a more compliant loading curve. All mesh approaches held up at extreme quasistatic loads.

CONCLUSION

Subtle differences in biomechanical properties highlight the strengths of each closure type and suggest possible uses. The failure mechanisms seen here support the known hypotheses for early fascial dehiscence. The influence of dynamic loading needs to be investigated further in future studies.

Is there a role for botulinum toxin A in the emergency setting for delayed abdominal wall closure in the management of the open abdomen? A systematic review

INTRODUCTION

Emergency laparotomy for either trauma or non-trauma indications is common and management is varied. Use of the open abdomen technique allowing for planned re-look is an option; however, performing delayed definitive fascial closure (DFC) following this can be a challenge. The use of botulinum toxin-A (BTX) infiltration into the lateral abdominal wall has been well documented within the elective setting; its use within the emergency setting is undecided. This systematic review assesses the efficacy and safety of BTX injection into the lateral abdominal wall muscles in the emergency setting. The primary outcome is DFC rate.

METHODS

Systematic review was performed according to the PROSPERO registered protocol (CRD42020205130). Papers were dual screened for eligibility, and included if they met pre-stated criteria where the primary outcome was DFC. Articles reporting fewer than five cases were excluded. Bias was assessed using the Cochrane Risk of Bias and Joanna Brigg's appraisal tools.

FINDINGS

Fourteen studies were screened for eligibility, twelve full texts were reviewed and two studies were included. Both studies showed evidence of bias due to confounding factors and lack of reporting. Both studies suggested significantly higher rates of DFC than reported in the literature against standard technique (90.7% vs 66%); however, these data are difficult to interpret due to strict study inclusion criteria or lack of a control population.

CONCLUSION

The use of BTX is deemed safe and its effects in the emergency situation may have great potential. Unfortunately, to date, there is insufficient evidence to facilitate opinion.

Distinctive characteristics of granulation tissue in laparotomy wounds with underlying oncological processes

This study aimed to investigate the effects of malignant neoplasms on the morphological characteristics of laparotomy wound granulation tissue in the muscular-aponeurotic layer. The study involved a sample of 34 deceased individuals who had undergone abdominal organ surgery. Biopsy samples were taken from the muscular-aponeurotic layer of the anterior abdominal wall and subjected to histological examination, including staining with hematoxylin and eosin and methylene blue/Chromotrope 2B using N.Z. Slinchenko's method. Descriptive methods and morphometry were used to evaluate pathomorphological changes. The results suggest that malignant neoplasms significantly impede and decelerate the maturation of laparotomy wound granulation tissue. Surgeries performed at the late stages of abdominal organ malignant neoplasms result in an uneven and slow maturation of the tissue, characterized by a higher prevalence of lymphoid cells, increased blood vessel volume, reduced optical density of stained collagen fibers, and pronounced chromotropophilia of collagen fibers. These distinct features should be considered to prevent postoperative eventration, a complication that is more likely to occur in this patient group. Clinicians should be aware of the possible consequences of malignant neoplasms on laparotomy wound granulation tissue, which may require additional measures to prevent postoperative complications in these patients.

Fascial dehiscence: predictable complication? Development and validation of a risk model: a retrospective cohort study

PURPOSE

Fascial dehiscence is still an important cause of morbidity and mortality in the postoperative period of abdominal surgery. Different authors have sought to identify risk factors for this entity. Two risk scores have been developed, but they include postoperative variables, which hinder preventive decision-making during the early surgical period. Our aim is to identify preoperative and intraoperative risk factors for fascial dehiscence and to develop and validate a risk prediction score that allows taking preventive behaviors.

METHODS

All adult patients, with no prior history of abdominal surgery, who underwent midline laparotomy by a general surgery division between January 2009 and December 2019 were included. Recognized preoperative risk factors for fascial dehiscence were evaluated in a univariate analysis and subsequently entered in a multivariate stepwise logistic regression model. A prognostic risk model was developed and posteriorly validated by bootstrapping. This study was conducted following the STROBE statement.

RESULTS

A total of 594 patients were included. Fascial dehiscence was detected in 41 patients (6.9%). On multivariate analysis, eight factors were identified: chronic obstructive pulmonary disease (COPD), immunosuppression, smoking, prostatic hyperplasia, anticoagulation use, sepsis, and overweight. The resulting score ranges from 1 to 8. Scores above 3 are predictive of 18% risk of dehiscence with a sensitivity of 70% and specificity of 80% (ROC 0.88).

CONCLUSIONS

We present a new preoperative prognostic score to identify patients with a high risk of fascial dehiscence. It can be a guide for decision-making that allows taking intraoperative preventive measures. External validation is still required.

The effectiveness of transabdominal cerclage placement via laparoscopy or laparotomy: a systematic review and meta-analysis

OBJECTIVE

Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.

DATA SOURCES

We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.

STUDY ELIGIBILITY CRITERIA

All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.

METHODS

All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.

RESULTS

Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.

CONCLUSION

Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.

[Choice of surgical approach and option for completing laparotomy in widespread peritonitis]

OBJECTIVE

To create a system for choosing surgical approach and completing laparotomy in advanced secondary peritonitis via combination of clinical, visual intra-abdominal criteria and systems for predicting the outcomes of peritonitis.

MATERIAL AND METHODS

The study included 686 patients with peritonitis between May 2015 and December 2022. Age of patients ranged from 16 to 95 years (mean 53.4±8.7). Male-to-female ratio was 1.2:11 (377:309). Destructive appendicitis was the cause of peritonitis in 274 (39.9%) patients, gastroduodenal ulcer perforation - 160 (23.3%) patients, colonic perforation - 188 (27.4%) patients, other causes - 64 (9.4%) patients. At baseline, 481 (70.1%) patients underwent diagnostic laparoscopy, and laparoscopic surgery was possible in 302 (62.8%) cases. Primary median laparotomy was performed in 205 (29.9%) patients. The closed method of completing laparotomy was used in 345 patients (77 - 22.3% died), staged elective surgeries - 28 (18 - 64.3% died), open abdomen technique was used in 11 patients (5 - 45.5% died). Redo laparotomy on demand was performed in 44 patients. Of these, 21 (47.7%) ones died. Overall mortality was 15.0% (n=103). The main causes of mortality were sepsis/septic shock (67 cases, 65.0%), acute cardiovascular and respiratory failure (15 patients, 14.6%).

RESULTS

The developed index of approach and completion of surgery in secondary peritonitis is valuable to make a decision on access and completion of surgery in patients with widespread peritonitis.

CONCLUSION

Integral systems for assessment of clinical status and choice of treatment strategy are effective in systematizing the results, evaluating treatment outcomes and conducting researches.

Continuous and interrupted abdominal-wall closure after primary emergency midline laparotomy (CONIAC-trial): study protocol for a randomised controlled single centre trial

INTRODUCTION

The optimal closure of the abdominal wall after emergency midline laparotomy is still a matter of debate due to lack of evidence. Although closure of the fascia using a continuous, all-layer suture technique with slowly absorbable monofilament material is common, complications like burst abdomen and hernia are frequent.

METHODS AND ANALYSIS

This randomised controlled trial with a 1:1 allocation evaluates the efficacy and safety of a continuous suture with or without additional interrupted retention sutures for closure of the abdominal fascia. Patients with an indication for a primary emergency midline laparotomy are eligible to participate in this study and will be randomised intraoperatively via block randomisation. Fascia closure in the intervention group will be done with a standard continuous suture with slowly absorbable monofilament material (MonoMax 1, B. Braun, Tuttlingen, Germany) and additional interrupted retention sutures every 2 cm of the fascia using rapidly absorbable braided material (Vicryl 2, Ethicon, Norderstedt, Germany). In the control group, the fascia is closed only with the standard continuous suture with slowly absorbable monofilament material. Sample size calculations (n=111 per study arm) are based on the available literature. The primary endpoint is the rate of dehiscence of the abdominal fascia (rate of burst abdomen within 30 days or rate of incisional hernia within 12 months). Secondary endpoints are wound infections, quality of life, length of hospital stay, morbidity and mortality. Patients as well as individuals involved in data collection, endpoint assessment, data analysis and quality of life assessment will be blinded.

ETHICS AND DISSEMINATION

The study protocol, the patient information and the informed consent form have been approved by the ethics committee of the Ludwig-Maximilians-University, Munich, Germany (reference number: 20-1041). Study findings will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00024802.

WHO UNIVERSAL TRIAL NUMBER

U1111-1259-1956.

Management of a giant uterine smooth muscle tumor of uncertain malignant potential in a 32-year-old woman: case report and review of the literature

Uterine smooth muscle tumors of uncertain malignant potential (STUMP) represent a group of rare uterine smooth muscle tumors not diagnosed unequivocally as benign or malignant. To data, diagnostic criteria, malignant potential, surgical management, and follow-up of these neoplasms remain controversial. Considering that STUMP and leiomyoma are not significantly different in terms of clinical presentation and preoperative sonographic characteristics, it might be difficult to distinguish between the two affections prior to pathological confirmation at surgery. All cases should be managed by multidisciplinary tumor teams and patients' follow-up should comprise consultation with a gynecologic oncologist and a close surveillance because of the possibility of recurrence or metastasis. We present the case of a 32-year-old nulliparous woman admitted to our gynecology clinic. She was asymptomatic and only complained an increase in abdominal volume started during the past 6 months. A transabdominal and transvaginal pelvic ultrasound revealed a large heterogeneous tumor mass measuring 190×163 mm, color score 2, expanded in the left iliac fossa, suspected for benign uterine myoma. Subsequent magnetic resonance imaging confirmed a large pelvic-abdominal tumor located near the left posterior-lateral uterine wall with areas of necrosis, suggestive of subserosal leiomyoma with cystic degeneration. The patient underwent a median longitudinal laparotomy for excision of the pelvic mass. The patient was normally discharged five days after surgery in good health conditions. The final histological examination was compatible with STUMP. At present, the patient has had no relapses or metastases and she is undergoing follow-up.

Prevention of Incisional Hernias by Prophylactic Mesh-augmented Reinforcement of Midline Laparotomies for Abdominal Aortic Aneurysm Treatment: Five-year Follow-up of a Randomized Controlled Trial

INTRODUCTION

The incidence of incisional hernias (IHs) after open repair of an abdominal aortic aneurysm (AAA) is high. Several randomized controlled trials have reported favorable results with the use of prophylactic mesh to prevent IHs, without increasing complications. In this analysis, we report on the results of the 60-month follow-up of the PRIMAAT trial.

METHODS

In a prospective, multicenter, open-label, randomized design, patients were randomized between prophylactic retrorectus mesh reinforcement (mesh group), and primary closure of their midline laparotomy after open AAA repair (no-mesh group). This article reports on the results of clinical follow-up after 60 months. If performed, ultrasonography or computed tomography were used for the diagnosis of IHs.

RESULTS

Of the 120 randomized patients, 114 were included in the intention-to-treat analysis. Thirty-three patients in the no-mesh group (33/58-56.9%) and 34 patients in the mesh group (34/56-60.7%) were evaluated after 5 years. In each treatment arm, 10 patients died between the 24-month and 60-month follow-up. The cumulative incidence of IHs in the no-mesh group was 32.9% after 24 months and 49.2% after 60 months. No IHs were diagnosed in the mesh group. In the no-mesh group, 21.7% (5/23) underwent reoperation within 5 years due to an IH.

CONCLUSIONS

Prophylactic retrorectus mesh reinforcement after midline laparotomy for the treatment of AAAs safely and effectively decreases the rate of IHs. The cumulative incidence of IHs after open AAA repair, when no mesh is used, continues to increase during the first 5 years after surgery, which leads to a substantial rate of hernia repairs.

Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization.

METHODS

A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated.

RESULTS

Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity.

CONCLUSION

We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema.

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level IV.

Effects of the short stitch technique for midline abdominal closure on incisional hernia (ESTOIH): randomized clinical trial

BACKGROUND

Incisional hernia remains a frequent problem after midline laparotomy. This study compared a short stitch to standard loop closure using an ultra-long-term absorbent elastic suture material.

METHODS

A prospective, multicentre, parallel-group, double-blind, randomized, controlled superiority trial was designed for the elective setting. Adult patients were randomly assigned by computer-generated sequence to fascial closure using a short stitch (5 to 8 mm every 5 mm, USP 2-0, single thread HR 26 mm needle) or long stitch technique (10 mm every 10 mm, USP 1, double loop, HR 48 mm needle) with a poly-4-hydroxybutyrate-based suture material (Monomax®). Incisional hernia assessed by ultrasound 1 year after surgery was the primary outcome.

RESULTS

The trial randomized 425 patients to short (n = 215) or long stitch technique (n = 210) of whom 414 (97.4 per cent) completed 1 year of follow-up. In the short stitch group, the fascia was closed with more stitches (46 (12 s.d.) versus 25 (7 s.d.); P < 0.001) and higher suture-to-wound length ratio (5.3 (2.2 s.d.) versus 4.0 (1.3 s.d.); P < 0.001). At 1 year, seven of 210 (3.3 per cent) patients in the short and 13 of 204 (6.4 per cent) patients in the long stitch group developed incisional hernia (odds ratio 1.97, 95 per cent confidence interval 0.77 to 5.05; P = 0.173).

CONCLUSION

The 1-year incisional hernia development was relatively low with clinical but not statistical difference between short and long stitches. Registration number: NCT01965249 (http://www.clinicaltrials.gov).

Surgical contraception of free-ranging female capybaras: Description and comparison of open and minimally invasive techniques

OBJECTIVE

To develop, describe, and evaluate 2 surgical techniques for contraception of free-ranging female capybaras.

STUDY DESIGN

Prospective study.

ANIMALS

Cadaveric (n = 3) and free-ranging female capybaras (n = 21).

METHODS

Preliminary studies of surgical anatomy were performed on 3 capybara cadavers. Two different techniques for partial salpingectomy were evaluated in free-ranging female capybaras: bilateral minilaparotomy (LTG; n = 11) or bilateral laparoscopy (LCG; n = 10). Data concerning body weight, tubal ligation time, total surgical time, incision size, and intraoperative and postoperative complications were analyzed, as well as the clinical status and incisional healing 1 week postoperatively.

RESULTS

Body weight (P = .214), ligation time of the left uterine tube (P = .901), and total surgical time (P = .473) were similar between the experimental groups. The ligation time of the right uterine tube was shorter in the LCG group (P = .0463). In the LTG, no differences were observed between the sides regarding the incision size (P = .478). No major intraoperative or postoperative complications occurred in either group. One LCG procedure had to be converted to LTG due to technical issues. All skin incisions healed without complication.

CONCLUSION

Both procedures showed similar and satisfactory outcomes.

CLINICAL SIGNIFICANCE

The proposed techniques may be a suitable alternative to conventional laparotomy for contraception of female capybaras, especially under field conditions.

Spontaneous reduction of transvaginal small bowel evisceration after abdominal hysterectomy for cervical cancer: A case report

RATIONALE

Transvaginal evisceration of the small bowel is an extremely rare condition after hysterectomy, which requires urgent surgical intervention to prevent serious bowel morbidity and mortality.

PATIENT CONCERNS

A 65-year-old woman presented with sudden-onset severe abdominal pain and a mass protruding through the vagina. The past surgical history was significant, with an abdominal hysterectomy for cervical cancer performed 11 weeks prior to presentation.

DIAGNOSIS

Pelvic examination revealed prolapsed small-bowel loops (18-20 cm in length). Pelvic computed tomography scan confirmed the presence of transvaginal evisceration of the small bowel.

INTERVENTIONS

Bowel reduction and urgent laparotomy were the selected treatment approaches for a detailed inspection and thorough washing of the intrα-abdominal cavity. A Foley catheter was inserted in the emergency room, with the subject in the lithotomy position. The prolapsed bowel loops spontaneously reduced without manual reduction, and the vault defect was repaired transvaginally.

OUTCOMES

The patient experienced no postoperative complications and remained disease-free for 9months postoperatively.

LESSONS

Transvaginal evisceration of the small bowel should be considered a surgical emergency. A multidisciplinary approach to prompt case management involving clinicians in gynecology, general surgery, and emergency medicine is vital for preventing serious consequences. Hysterectomy is the most frequently performed gynecological surgical procedure, and evisceration occurs most often after hysterectomy. Therefore, patients should be informed about this rare but possible hysterectomy complication.

THE ROLE OF ONCOLOGICAL PROCESS IN OCCURRENCE OF POSTOPERATIVE EVENTRATION

Eventration is one of the rare but the most dangerous postoperative complications in the abdominal surgery registered in 0.5-2.35% of patients. Eventration occurs most frequently after urgent surgery on the abdominal organs of weakened patients of the old and elderly ages with a low immune-biological condition of the body. Examination of certain specific features of eventration occurrence with underlying oncological process will allow better understanding the latter in the development of the postoperative complication. Therefore, the objective of the research was to examine experimentally the effect of malignant neoplasm on the mechanical strength of the laparotomy wound postoperative scar on small laboratory animals, and to study clinically occurrence of postoperative eventration development in patients with malignant neoplasms of the abdominal organs. The experimental studies were carried out on 78 laboratory rats operated on by means of laparotomy 3,0 cm in length. Heren's carcinoma was preliminary grafted under the skin of the external femoral surface in the main group of animals. The mechanical strength of the laparotomy wound scar was determined on the 1st, 3rd and 5th days after surgery by means of measuring abdominal pressure at the moment of scar rupture. 140 were examined who underwent midline laparotomy for surgical treatment of abdominal diseases. The main group included 98 patients with malignant neoplasms of the abdominal organs who were divided into two groups depending on the stages of oncological process. The first subgroup included 46 individuals at the I-II stages of the disease, and the second subgroup of the main group included 52 patients at the II-IV stages of the disease. The group of comparison involved 42 patients with acute surgical non-oncological pathology of the abdominal organs. Both groups of patients were comparable by the age and gender. An average age of patients in both groups of the study was 60.1±0.95 years. An average length of the laparotomy wound was 27.1±0.25 cm. The obtained results were statistically processed on the personal computer by means of electronic tables Microsoft Excel and the package of statistical processing program IBM SPSS Statistics. The results of the experimental studies are indicative of the fact that malignant process in the body results not only in inhibited maturation of the granulation tissue in the laparotomy wound, but in reduced strength of the postoperative scar beginning with the 3rd day after surgery performed. Analysis of the results of our clinical study enables to admit reliable increase of occurrence of "local" postoperative complications including suppuration of the postoperative wound and eventration, especially when oncological process is at the late stages of the disease. This specific feature should be considered when sutures and drainage are applied on the laparotomy wound in this group of patients. Thus, oncological process at the late stages of the disease promotes reduced strength of the laparotomy wound postoperative scar and results in an increased occurrence of eventration and suppuration of the postoperative wound.

Laparotomic radical hysterectomy versus minimally invasive radical hysterectomy using vaginal colpotomy for the management of stage IB1 to IIA2 cervical cancer: Survival outcomes

This study compared survival outcomes for patients with stage IB1 to IIA2 (International Federation of Gynecology and Obstetrics stage 2009) cervical cancer who underwent open radical hysterectomy (ORH) versus those who underwent minimally invasive radical hysterectomy (MIRH) using vaginal colpotomy (VC).Data for 550 patients who were diagnosed with cervical cancer at our institution during the period August 2005 to September 2018 was retrospectively reviewed. Of these, 116 patients who underwent radical hysterectomy (RH) were selected after applying the exclusion criteria. All MIRH patients underwent VC. Clinicopathological characteristics and survival outcomes between the ORH and MIRH groups were compared using appropriate statistical testing.Ninety one patients were treated with ORH and 25 with MIRH during the study period. Among the MIRH patients, 18 underwent laparoscopy-assisted radical vaginal hysterectomy and 7 underwent laparoscopic RH. Preoperative conization was performed more frequently in MIRH patients than in ORH patients (44% vs 22%, respectively, P = .028). The incidence of lymph node invasion was higher in the ORH group than in MIRH group (37.4% vs 12.0% respectively; P = .016). Following RH, ORH patients underwent adjuvant treatment more frequently than MIRH patients (71.4% vs 56.0%, respectively, P = .002). There were no significant differences between ORH and MIRH patients for either progression-free survival (PFS) (91.3% vs 78.7%, respectively; P = .220) or 5-year overall survival (OS) (96.6% vs 94.7%, respectively, P = .929). In univariate analysis, lympho-vascular space invasion was the only clinicopathological feature associated with decreased PFS. No other clinicopathological factors was significantly associated with PFS or OS in univariate and multivariate analyses.Despite a higher incidence of unfavorable prognostic factors in ORH patients, their survival outcomes were not different to those of MIRH patients with VC.

Postoperative lymphocyst formation after pelvic lymphadenectomy for gynecologic cancers: comparison between laparoscopy and laparotomy

PURPOSE

The goal of this study was to evaluate, using definitive diagnostic criteria, the incidence of lymphocyst formation following pelvic lymphadenectomy for gynecological cancer, and to compare rates between the approaches of laparoscopy and laparotomy.

METHODS

We retrospectively reviewed the medical records of all patients who underwent pelvic lymphadenectomy for cervical or endometrial cancer between March of 2010 and March of 2016. We defined a lymphocyst as a circumscribed collection of fluid within the pelvic cavity, with a diameter of 2 cm or more, as diagnosed with ultrasound or computed tomography.

RESULTS

During the six-year observational period, a pelvic lymphadenectomy was conducted in 196 women with clinical stage I uterine cancer; 90 cases underwent laparoscopy, 106 underwent laparotomy. The minimally invasive laparoscopic group had a lower estimated blood loss (p < 0.01), shorter hospital stay (p < 0.01). Lymphocysts were observed in 14.4% (13/90) of the laparoscopy cases, and in 15.1% (16/106) of the laparotomy cases which means no significant difference of lymphocyst (p = 1.00). The median size of symptomatic lymphocyst was significantly larger in laparotomy group than in laparoscopy group (4.8 cm v.s. 2.8 cm, median) (p = 0.04). Symptomatic lymphocysts were more common in laparotomy [7/90 (7.8%) vs 14/106 (13.2%) (p = 0.253)].

CONCLUSIONS

In a retrospective analysis with a strict diagnostic criteria, we could find no statistical difference in lymphocyst occurrence between laparoscopy and laparotomy. The median size of the lymphocyst was bigger and lymphocyst was likely to be symptomatic in the laparotomy group.

OUP accepted manuscript

Background

Despite the fact that emergency midline laparotomy is a risk factor for an incisional hernia, active research on hernia prevention in emergency settings is lacking. Different kinds of meshes and mesh positions have been studied in elective abdominal surgery, but no randomized controlled trials in emergency settings have been published thus far.

Method

The PREEMER trial (registration number NCT04311788) is a multicentre, patient- and assessor-blinded, randomized controlled trial to be conducted in six hospitals in Finland. A total of 244 patients will be randomized at a 1 : 1 ratio to either the retrorectus mesh group, featuring a self-gripping prophylactic mesh, or to the no mesh (control) group, both closed by small-stitch 4 : 1 closure with continuous slowly absorbable monofilament suturing. The primary outcome of the PREEMER trial is the incidence of incisional hernia 2 years after surgery, which will be detected clinically and/or radiologically. Secondary outcomes are the Comprehensive Complication Index score, incidence of surgical-site infections and fascial dehiscence within 30 days of surgery; the incisional hernia repair rate and mesh- or hernia-related reoperations within the 2- and 5-year follow-ups; the incidence of incisional hernia within the 5-year follow-up; and quality of life measured by RAND-36, the Activities Assessment Scale and the PROMIS questionnaire within 30 days and 2 and 5 years from surgery. Additionally, health–economic explorative measures will be explored.

Conclusion

The PREEMER trial will provide level 1 evidence on incisional hernia prevention in an emergency setting.

Registration number

NCT04311788 (http://www.clinicaltrials.gov). Registered 7 March 2020.

Manual Closed Reduction of Incarcerated Hernia: Is It Safe in the Emergency Department?

BACKGROUND

Emergency surgical repair is the standard approach to the management of an incarcerated abdominal wall hernia (IAWH). In cases of very high-risk patients, manual closed reduction (MCR) of IAWH may prevent the need for emergency surgery.

OBJECTIVES

To evaluate the safety, success rate, and complications of MCR in the management of IAWH conducted in an emergency department.

METHODS

The data of all patients who underwent MCR between 2012 and 2018 were retrospectively collected. Patient demographics, presenting symptoms, clinical parameters, and management during the hospitalization were retrieved from the medical charts.

RESULTS

Overall, 548 patients underwent MCR during the study period. The success rate was 25.4% (139 patients). One patient had a complication that required a laparotomy 2 days after his discharge. A recurrent incarceration occurred in 23%, 60% of them underwent successful repeated MCR and the others underwent emergency surgery. Six patients (1.4%) had a bowel perforation after a failed MCR.

CONCLUSIONS

MCR can be performed safely in the emergency department and should be consider as an option to treat IAWH, especially in high operative risk patients.

Decreasing Incisional Hernia by Teaching 4:1 Suture to Wound Length Ratio Early in Surgical Education

OBJECTIVE

Incisional hernia formation has become a major burden for our healthcare system. One factor that has been shown to reduce incisional hernia rates that can be impacted on by the surgeon is the ability to achieve a 4:1 suture to wound length ratio. The purpose of this study is to evaluate whether a focused educational program for surgical residents can help improve laparotomy closures and be successful in achieving 4:1 suture to wound length ratios.

DESIGN

Following Institutional Review Board approval, consecutive abdominal wall closures were reviewed from December 2013 to July 2016. S:W length ratios were calculated in all cases and after 100 cases a formal audit of success and risk factors for not achieving a 4:1 ratio was performed followed by a formal resident education on laparotomy closure. The ability to achieve a 4:1 ratio for the first 100 cases following resident education was then compared to the 100 patients preceding the education with a p-value of <0.05 considered significant.

RESULTS

Two hundred patients underwent midline laparotomy with S:W length ratio calculated. In the first 100 patients, 76% of patients received a 4:1 S:W closure. Following resident education, this improved to 90% in the second 100 patients (p = 0.0083). Among patients where 2 residents performed the abdominal closure, 50% got an adequate 4:1 closure. This improved to 92% for the second 100 patients (p = 0.016).

CONCLUSION

A 4:1 S:W length ratio is a simple technique that has been proven to decrease incisional hernia. It requires no additional cost and can easily be implemented into practice. The act of formal resident education and measuring suture tails to calculate a S:W ratio on each case holds surgeons accountable and improves success rate of achieving a 4:1 ratio.

Clinical Predictors of Unresectable Disease at Laparotomy in Patients With Pancreatic Ductal Adenocarcinoma Planning to Undergo Surgical Resection

BACKGROUND/AIM

Computed tomography and positron emission tomography cannot detect all minute distant metastases and fully evaluate extensive vascular invasion in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to investigate predictors of laparotomy only and palliative surgery in PDAC patients planning surgical resection.

PATIENTS AND METHODS

We reviewed 239 PDAC patients planning surgical resection. Patients were divided into two groups based on resection status. Multivariate analyses were performed to identify predictors of unresectable disease at laparotomy.

RESULTS

Twenty-five patients had unresectable disease at laparotomy. Multivariate analysis revealed that anatomical borderline resectable status (yes/no) (HR=5.458, p=0.012), pretreatment CA19-9 (>260/≤260 ng/ml) (HR=4.907, p=0.041), and tumor size (>25/≤25 mm) (HR=21.42, p=0.004) were associated with unresectable disease at laparotomy.

CONCLUSION

Borderline resectable status, pretreatment CA19-9, and tumor size were closely associated with unresectable disease at laparotomy in PDAC patients planning surgical resection.

Outcomes in Endoscopic and Operative Transgastric Pancreatic Debridement

OBJECTIVES

Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement (TGD). We compared our experience with these 2 approaches.

SUMMARY BACKGROUND DATA

Select necrotizing pancreatitis (NP) patients are suitable for TGD which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists.

METHODS

Patients undergoing Endo-TGD and OR-TGD at a single, high-volume pancreatic center between 2008 and 2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these 2 groups were compared.

RESULTS

Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. OR-TGD required 1.1 ± 0.5 and Endo-TGD 3.0 ± 2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New-onset organ failure [Endo-TGD (13%); OR-TGD (13%); P = 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 ± 20.8 days) compared to OR-TGD (9.4 ± 6.1 days; P = 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P = 0.04).

CONCLUSIONS

Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients.