Faculty Bibliography

BACKGROUND:Abdominal wall reconstruction (AWR) carries significant postoperative morbidity, including surgical site infection, wound dehiscence, and readmission. Frailty and sarcopenia have emerged as critical predictors of surgical outcomes; however, their role in AWR is not well defined. We aimed to evaluate the independent and combined predictive value of frailty and sarcopenia proxies on morbidity and mortality after AWR. METHODS:A retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted from 2015 to 2020. Frailty was assessed using the Modified Frailty Index (mFI-5), and sarcopenia proxies were defined by ≥ 1 validated proxy markers (BMI < 20, > 10% weight loss/malnutrition, hypoalbuminemia, hematocrit < 30%). Propensity score matching (PSM) was performed to create balanced cohorts, and conditional logistic regression on matched pairs was used to evaluate associations between frailty, sarcopenia proxies, and postoperative outcomes. Primary outcomes were 30-day morbidity and mortality. RESULTS:15,466 adult patients undergoing elective AWR were included. Frailty and sarcopenia proxies were present in 19.4% and 11.3% of patients, respectively. After propensity score matching, frailty was associated with increased odds of overall morbidity (OR 1.16, 95% CI 1.01-1.32; p = 0.035), major complications (OR 1.27, 95% CI 1.07-1.52; p = 0.008), and discharge to a non-home facility (OR 1.40, 95% CI 1.09-1.80; p = 0.008). Sarcopenia proxies demonstrated similar associations. The combined frailty and sarcopenia-proxy phenotype (dual-impairment) conferred the highest odds of morbidity, major complications, and discharge to a non-home facility. Thirty-day mortality and operative time did not differ significantly between groups after matching. CONCLUSION/CONCLUSIONS:Frailty and sarcopenia proxies are prevalent among patients undergoing elective AWR and are independently associated with increased postoperative morbidity, with their coexistence (dual-impairment) conferring the greatest risk. Incorporating these factors into risk calculators may improve patient selection, nutritional optimization, and prehabilitation strategies in complex hernia repair.

BACKGROUND:Parastomal hernia repair is technically complex and associated with substantial morbidity, yet disparities in outcomes among racial groups have not been evaluated. Identifying inequalities in this population may inform strategies to improve access and perioperative care. METHODS:The ACS-NSQIP database from 2013 to 2023 was queried for adults undergoing parastomal hernia repair. Demographics, comorbidities, and operative details were compared among White patients, Black patients, and Hispanic patients. Primary outcomes included 30-day morbidity, infectious complications, and length of stay (LOS). Multivariable logistic and linear regression models were performed using a two step forward selection model adjusting for comorbidities and surgical details. RESULTS:A total of 3,513 patients were included (White 85, Black 8, Hispanic 7%). Black patients had higher unadjusted rates of morbidity (38 vs 30 White, 32% Hispanic; p = 0.023), serious complications (20 vs 13% white vs 13% Hispanic, p = 0.008), infectious complications (20 vs 13 White, 15% Hispanic; p = 0.004), and longer median LOS (6 vs 5 days White, 6 days Hispanic; p = 0.005). On multivariable analysis, Black race remained independently associated with increased odds of overall morbidity (aOR 1.31, 95% CI 1.01-1.70; p = 0.043), serious complications (aOR 1.65; CI 1.15-2.34, p = 0.006), and infectious complications (OR 1.44, 95% CI 1.04-1.98, p = 0.026) compared to white patients. CONCLUSION/CONCLUSIONS:This is the first national study to characterize racial disparities in parastomal hernia repair. Black patients experienced higher morbidity, infectious complications, and length of stay compared to White patients, while Hispanic patients did not differ from White patients. Disparities were emphasized in emergent cases, suggesting that barriers to timely elective repair possible drive imbalances in parastomal hernia repair, warranting interventions for underserved populations, with early referral, equal access, and tailored perioperative support.

INTRODUCTION/BACKGROUND:Inguinal hernia is a common occurrence affecting one in four men. Recurrence is a major clinical pitfall that affects about 10% of patients with increased recurrence and postoperative complications after a revision repair. Reoperation due to metachronous contralateral inguinal hernia is another possible outcome. The impact of minimally invasive surgery (MIS) techniques on inguinal hernia recurrence rates as compared to open surgery is less clear and further confounded by the adoption of robotic approaches. The aim of this study was to compare reoperation rates. METHODS:MarketScan® Research Databases. Reoperation for IHR within two years was compared across surgical approaches: Open (O-IHR), Laparoscopic (L-IHR), and Robotic (R-IHR). Reoperations were further categorized and analyzed separately for recurrent and non-recurrent IHR. Secondary outcomes included all-cause total healthcare expenditures, assessed during the index operation and up to two years postoperatively, based on combined insurer and patient payments. A 1:1 propensity score matching approach was applied, with Cox proportional hazards regression used to analyze reoperation risk, and generalized linear regression models employed to evaluate expenditures. RESULTS:A total of 73,870 patients undergoing IHR (39,591 [53.6%] O-IHR, 30,858 [41.8%] L-IHR, and 3,421 [4.6%] R-IHR) were included. As compared to O-IHR, any IHR reoperation risk at 2-years was about 42% lower with R-IHR (HR = 0.58, p = 0.002) and about 16% lower with L-IHR (HR= 0.84, p < .001). As compared to O-IHR, total expenditure for the index surgery was approximately $3,391 higher with L-IHR (p < .001) and $4,137 higher with R-IHR (p < .001). R-IHR had about $615 higher index expenditure than L-IHR (p = 0.004). CONCLUSION/CONCLUSIONS:The current study demonstrates that robotic IHR is associated with a lower risk of reoperations at 2 years after an initial repair as compared to L-IHR and O-IHR, but higher index expenditure in the outpatient setting for an economically active population.

PURPOSE/OBJECTIVE:The aim of this study was to compare robotic-assisted versus laparoscopic techniques in elective primary minimally invasive inguinal hernia repair, focusing on intraoperative conversion rates, perioperative outcomes, and preoperative risk factors. Given the increasing adoption of robotic surgery, we sought to evaluate whether the proposed technical advantages translate into measurable clinical benefits in a real-world, multicenter population using a nationally representative database. METHODS:A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2022-2023). Adult patients undergoing elective minimally invasive inguinal hernia repair were identified using CPT code 49650. Patients were stratified into robotic and laparoscopic cohorts. Primary outcomes included conversion to open surgery and operative time; secondary outcomes included 30-day complications, mortality, hospital length of stay, and readmission. Statistical analyses included univariate and multivariate logistic regression. RESULTS:Of 34,257 cases analyzed, 54.9% were robotic and 45.1% laparoscopic. Robotic cases had significantly lower conversion to open rates (0.1% vs. 0.4%, p < 0.001) but longer operative times (82.5 vs. 65 min, p < 0.001). Perioperative complications, mortality, and readmission rates were comparable between groups. Multivariate analysis showed robotic surgery as an independent protective factor against conversion (OR 0.36, 95% CI: 0.22-0.57, p < 0.001). CONCLUSION/CONCLUSIONS:Robotic-assisted inguinal hernia repair is associated with a lower conversion rate to open surgery without increased complications, despite longer operative times and a higher comorbidity burden. These findings support the selective use of robotics, particularly in complex cases, while highlighting the need for further cost-effectiveness and long-term outcomes research.

INTRODUCTION/BACKGROUND:Barbed sutures in ventral hernia repair have been used increasingly. The impact that barbed sutures has on operative time in other procedures is well documented but few reports on ventral hernia repair exist. Furthermore, the use of barbed sutures varies across surgical approaches. The aim of this study was to explore the operative time for ventral hernia repair elucidated by open, laparoscopic, or robotic approach. METHODS:Patients who underwent ventral hernia repair with fascial closure from 2020 to 2022 from the Abdominal Core Health Quality Collaborative were included. Propensity score matching 1:1 with covariates of age, American Society of Anesthesiologists class, recurrent, wound status, incisional procedure, hernia width, mesh used and type, mesh location, body mass index capped at 15 to 60, and concomitant procedures was performed by operative approach. The primary outcome of interest was operative time, and secondary outcomes were length of stay, surgical site infections, surgical site occurrences, surgical site occurrences requiring procedural intervention at 30-day follow-up. RESULTS:A total of 2,230 patients were included in propensity score matchings: open ventral hernia repair (n = 1,434), laparoscopic ventral hernia repair (n = 252), and robotic ventral hernia repair (n = 544). Operative time was more frequently >2 hours in robotic ventral hernia repair using nonbarbed sutures (58% vs 47%; P = .006) and was similar for open (60% vs 57%; P = .2) or laparoscopic (15% vs 21%; P = .2) approach. Across all operative modalities, using barbed sutures was strongly associated with fixation of mesh with sutures, closure of fascia in a running fashion, and more versatility in mesh locations, specifically in laparoscopic ventral hernia repair. Open ventral hernia repair had a shorter length of stay in patients with barbed sutures (2 vs 3; P = .003); however, a reoperation was more common in this same group (3% vs 1%; P = .03), specifically for recurrence (1% vs 0%; P = .04). All the other 30-day outcomes were similar across surgical approaches. CONCLUSION(S)/CONCLUSIONS:The usage of barbed sutures was associated with shorter operative time for robotic procedures and appears to influence the overall technique used in ventral hernia repair. Higher complexity laparoscopic ventral hernia repair performed with barbed sutures had a similar operative time to simpler ventral hernia repair performed with nonbarbed sutures. Open ventral hernia repair with barbed sutures might experience an increase in early recurrences. Further studies are needed.

Schistosomiasis is a parasitic disease caused by blood flukes commonly found in sub-Saharan Africa and select other areas in Asia and the Americas. The disease can manifest in a wide range of acute and chronic conditions, rarely presenting as acute appendicitis. Herein we report a case of a 36-year-old female patient from a nonendemic area (New York City) with a history of travel presenting with acute appendicitis secondary to instestinal schistosomiasis.

BACKGROUND:The National Surgical Quality Improvement Program (NSQIP) American College of Surgeons (ACS) risk calculator is a validated method of predicting postoperative complications that was recently updated to a machine-learning structure. The objective of this study was to measure the accuracy of this calculator in our institution on paraoesophageal hernia (PEH) repair. METHOD/METHODS:Procedures performed between 2019 and 2023 were retrospectively collected regarding demographics, operative variables, and outcomes with a 30-day follow-up. Thirteen outcomes measured by NSQIP-ACS calculator were measured. Observed and predicted rates were compared by receiver operating curves (ROC) and length of stay was compared by Wilcoxon signed rank test. RESULTS:A total of 203 paraoesophageal hernia repairs on patients with a median age of 68 (IQR 61-75) and 70.9% (n = 144) predominantly female. The size of the paraoesophageal hernia (PEH) was large or giant in 59.1% (n = 120) and mesh was placed in 70.4% (n = 143). The predicted risk was consistently higher than observed events on all but discharge destinations. Eight outcomes had no event to measure; however, the calculator accurately predicted a risk of ≤ 1% on all of these. The area under the curve (AUC) was fair (0.6-0.79) on discharge to nursing or rehabilitation facilities and failed in the rest of the measurable outcomes. CONCLUSION/CONCLUSIONS:The ACS-NSQIP risk calculator correctly predicted a low occurrence of postoperative outcomes in patients undergoing robotic paraoesophageal hernia repair.