Pfannenstiel Specimen Extraction Reduces Risk of Incisional Hernia in Colorectal Operations
Johnson JA, Mesiti A, Herre M, et al. Effect of Specimen Extraction Site on Postoperative Incisional Hernia after Minimally Invasive Right Colectomy. J Am Coll Surg. 2024, in press.
Invited Contribution: Abelson JS. There Is No Doubt: Avoid Midline Extraction when Feasible in Minimally Invasive Colorectal Surgery to Minimize Risk of Incisional Hernia. J Am Coll Surg. 2024, in press.
Incisional hernia is a significant complication of minimally invasive colorectal surgical procedures and is an important cause of decreased postoperative quality of life. Although incisional hernia risk has decreased with increasing use of minimally invasive surgical approaches, this condition is diagnosed in up to 14% of patients undergoing minimally invasive colorectal procedures. Available evidence has suggested that the location of the specimen extraction incision (midline vs. Pfannenstiel) is associated with risk for incisional hernia. This study used retrospective patient data (n = 341) from two large academic medical centers to determine the frequency of incisional hernia after midline or Pfannenstiel specimen extraction. The data analysis showed that risk of incisional hernia was greatest following midline specimen extraction (25%) compared with Pfannenstiel extraction (0%). The authors concluded that extraction via a Pfannenstiel incision was preferable. In the editorial that accompanied this article, Abelson noted that the study had a strong sample size and clearly demonstrated the advantages of the Pfannenstiel extraction site. Limitations of the study included lack of data on incision length, wound classification, and type of suture used for closure. Despite these limitations, the evidence supports the use of Pfannenstiel extraction when feasible.
Surgical Smoke Is Not Linked to Transmission of Serious Disease, Microbial Transmission
Hurst RD, Stewart CL. Hazards of Surgical Smoke from Electrocautery: A Critical Review of the Data. Am J Surg. 2024.
“Surgical smoke” is a term used to describe the water vapor and minute amounts of particulate material produced in association with use of intraoperative electrocautery devices; these substances have been thought to cause symptoms such as cough, sore throat, and eye irritation, and there has been speculation that exposure to surgical smoke could aggravate conditions such as asthma, cardiovascular disease, and chronic obstructive pulmonary disease. Spread of viral and bacterial disease because of exposure to surgical smoke also has been suggested as a hazard. Statements from healthcare professional organizations have supported the use of designated smoke removal devices for procedures where electrocautery is employed. This article evaluated the strength of the available evidence supporting these hazards and the need for smoke evacuation devices. The findings of this literature review are encouraging in that the evidence supporting infection transmission and increased risk for major diseases is very weak. Strong evidence is available to show that the operating room ventilation systems currently in use are very effective and that levels of particles and vaporized substances associated with use of electrocautery are significantly below dangerous levels without use of evacuation devices. The authors concluded that significant risks for serious diseases and microbial transmission due to surgical smoke exposure are not supported by available evidence; the evidence also does not support routine use of specialized smoke evacuation devices. The review is very thorough and clearly presented. Surgeons are encouraged to read the full content of the article.
Surgery Delays of More than 14 Days Due to COVID Are Unnecessary
Leeds IL, Park LS, Akgun K, Weintrob A, Justice AC, King JT Jr. Postoperative Outcomes Associated with the Timing of Surgery after SARS-CoV-2 Infection. Ann Surg. 2024.
Because evidence gathered during the COVID pandemic suggested an increased risk of mortality and postoperative complications for an operative procedure performed less than 7 weeks following resolution of active COVID infection, delaying elective operations for 7 weeks following infection has become a common practice. Reassessment of this practice was necessary because decreased symptom severity and shorter duration of symptoms have become common as the COVID virus and human immunity have changed over time. In addition, there have been adverse effects as a result of delays in surgery.
This study examined a large Veterans Health Administration database to determine the safest interval between COVID infection and a needed elective surgical procedure. A cohort of patients (n = 82,815) with documented COVID infection who underwent a surgical procedure (general surgical, orthopaedic, urologic, and vascular) were categorized into comparison groups by 2-week intervals and rates of mortality and complications were recorded for each interval. The data showed that there was an increased risk for mortality and morbidity in patients who had been diagnosed with COVID, but this increased risk was not significant beyond 14 days after resolution of COVID infection. The authors concluded that delaying surgery for more than 14 days was not necessary based on the data from their study.
