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Climate change is one of the 21.sup.st century's biggest public health issues and health care contributes up to 10% of the emissions of greenhouse gases in developed countries. About 15 million laparoscopic procedures are performed annually worldwide and single-use medical equipment is increasingly used during these procedures. Little is known about costs and environmental footprint of this change in practice. We employed Life Cycle Assessment method to evaluate and compare the environmental impacts of single-use, reusable, and mixed trocar systems used for laparoscopic cholecystectomies at three hospitals in southern Sweden. The environmental impacts were calculated using the IMPACT 2002+ method and a functional unit of 500 procedures. Monte Carlo simulations were used to estimate differences between trocar systems. Data are presented as medians and 2.5.sup.th to 97.5.sup.th percentiles. Financial costs were calculated using Life Cycle Costing. The single-use system had a 182% higher impact on resources than the reusable system [difference: 5160 MJ primary (4400-5770)]. The single-use system had a 379% higher impact on climate change than the reusable system [difference: 446 kg CO.sub.2 eq (413-483)]. The single-use system had an 83% higher impact than the reusable system on ecosystem quality [difference: 79 PDF*m.sup.2 *yr (24-112)] and a 240% higher impact on human health [difference: 2.4x10.sup.-4 DALY/person/yr (2.2x10.sup.-4 -2.6x10.sup.-4 )]. The mixed and single-use systems had a similar environmental impact. Differences between single-use and reusable trocars with regard to resource use and ecosystem quality were found to be sensitive to lower filling of machines in the sterilization process. For ecosystem quality the difference between the two were further sensitive to a 50% decrease in number of reuses, and to using a fossil fuel intensive electricity mix. Differences regarding effects on climate change and human health were robust in the sensitivity analyses. The reusable and mixed trocar systems were approximately half as expensive as the single-use systems (17360 [euro] and 18560 [euro] versus 37600 [euro], respectively). In the Swedish healthcare system the reusable trocar system offers a robust opportunity to reduce both the environmental impact and financial costs for laparoscopic surgery.

Background No standardized written or volumetric definition exists for ‘loss of domain’ (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. Methods A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. Results Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. Conclusions Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

To study the cumulative incidence and surgical treatment of midline incisional hernia (MIH) after cystectomy for bladder cancer. In the nationwide Bladder Cancer Data Base Sweden (BladderBaSe), cystectomy was performed in 5646 individuals. Cumulative incidence MIH and surgery for MIH were investigated in relation to age, gender, comorbidity, previous laparotomy and/or inguinal hernia repair, operative technique, primary/secondary cystectomy, postoperative wound dehiscence, year of surgery, and period-specific mean annual hospital cystectomy volume (PSMAV). Three years after cystectomy the cumulative incidence of MIH and surgery for MIH was 8% and 4%, respectively. The cumulative incidence MIH was 12%, 9% and 7% in patients having urinary diversion with continent cutaneous pouch, orthotopic neobladder and ileal conduit. Patients with postoperative wound dehiscence had a higher three-year cumulative incidence MIH (20%) compared to 8% without. The corresponding cumulative incidence surgery for MIH three years after cystectomy was 9%, 6%, and 4% for continent cutaneous, neobladder, and conduit diversion, respectively, and 11% for individuals with postoperative wound dehiscence (vs 4% without). Using multivariable Cox regression, secondary cystectomy (HR 1.3 (1.0-1.7)), continent cutaneous diversion (HR 1.9 (1.1-2.4)), robot-assisted cystectomy (HR 1.8 (1-3.2)), wound dehiscence (HR 3.0 (2.0-4.7)), cystectomy in hospitals with PSMAV 10-25 (HR 1.4 (1.0-1.9)), as well as cystectomy during later years (HRs 2.5-3.1) were all independently associated with increased risk of MIH. The cumulative incidence of MIH was 8% three years postoperatively, and increase over time. Avoiding postoperative wound dehiscence after midline closure is important to decrease the risk of MIH.

IntroductionIncisional hernia has an incidence of up to 20% following laparotomy and is associated with significant morbidity and impairment of quality of life. A variety of surgical strategies including techniques and mesh types are available to manage patients with incisional hernia. Previous works have reported significant heterogeneity in outcome reporting for abdominal wall herniae, including ventral and inguinal hernia. This is coupled with under-reporting of important clinical and patient-reported outcomes. The lack of standardisation in outcome reporting contributes to reporting bias, hinders evidence synthesis and adequate data comparison between studies. This project aims to develop a core outcome set (COS) of clinically important, patient-oriented outcomes to be used to guide reporting of future research in incisional hernia.MethodsThis project has been designed as an international, multicentre, mixed-methods project. Phase I will be a systematic review of current literature to examine the current clinical and patient-reported outcomes for incisional hernia and abdominal wall reconstruction. Phase II will identify the outcomes of importance to all key stakeholders through in depth qualitative interviews. Phase III will achieve consensus on outcomes of most importance and for inclusion into a COS through a Delphi process. Phase IV will achieve consensus on the outcomes that should be included in a final COS.Ethics and disseminationThe adoption of this COS into clinical and academic practice will be endorsed by the American, British and European Hernia Societies. Its utilisation in future clinical research will enable appropriate data synthesis and comparison and will enable better clinical interpretation and application of the current evidence base. This study has been registered with the Core Outcome Measures in Effectiveness Trials initiative.PROSPERO registration numberCRD42018090084.

Background Bile duct injury (BDI) is a rare complication associated with cholecystectomy, and recommendations for treatment are based on publications from referral centers with a selection of major injuries and failures after primary repair. The aim was to analyze the frequency, treatment, and outcome of BDIs in an unselected population-based cohort. Methods This was a retrospective cohort study including all BDIs registered in GallRiks (Swedish quality register for gallstone surgery and ERCP) during 2007–2011. Data for this study were based on a national follow-up survey where medical records were scrutinized and BDIs classified according to the Hannover classification. Results A total of 174 BDIs arising from 55,134 cholecystectomies (0.3 %) identified at 60 hospitals were included with a median follow-up of 37 months (9–69). 155 BDIs (89 %) were detected during cholecystectomy, and immediate repair was attempted in 140 (90 %). A total of 27 patients (18 %) were referred to a HPB referral center. Hannover Grade C1 (i.e., small lesion <5 mm) dominated ( n  = 102; 59 %). The most common repair was “suture over T-tube” ( n  = 78; 45 %) and reconstruction with hepaticojejunostomy was performed in 30 patients (17 %). A total of 31 patients (18 %) were diagnosed with stricture, 19 of which were primarily repaired with “suture over T-tube.” The median in-hospital-stay was 14 days (1–149). Conclusions The majority of BDIs were detected during the cholecystectomy and repaired by the operating surgeon. Although this is against most current recommendations, short-term outcome was surprisingly good.

Background Topical negative pressure (TNP) therapy is increasingly used in open abdomen management. It is not known to what extent this pressure propagates through the dressing to the bowel surface, potentially increasing the risk of bowel fistula formation. The present study in a porcine model was designed to evaluate pressure propagation. Methods A commercially available TNP therapy system (ABThera/VAC) was applied in six pigs after laparotomy. Pressure sensors were placed in predetermined positions in the dressing and in the abdominal cavity and the pressure was registered at TNP settings of −50, −75, −100, −125, and −150 mmHg. Next, after infusing 200 ml of saline into the abdomen through a catheter, the amount of fluid drained through the system during 10 min of TNP therapy was registered. Finally, pressure was measured above and below eight layers of paraffin gauzes during TNP therapy. Results Observed pressure within the outer two foams and the foam of the visceral protective layer correlated with preset TNP. The median pressure at the bowel surface was between −2 and −10 mmHg, regardless of preset TNP. Median fluid drainage was 95% of the infused fluid at −75 mmHg and 124% at −150 mmHg. Paraffin gauzes had a limited isolating effect, reducing the pressure by 13% in median. Conclusions Negative pressure reaching the bowel surface during TNP therapy with the ABThera system is limited for all TNP levels. Reduced therapy pressure does not lead to reduced pressure at the bowel surface. The system drains the abdominal cavity completely of fluid. Paraffin gauzes are of limited value as a means of pressure isolation.

Purpose Incisional hernia repair (IHR) with a mesh is necessary to achieve low recurrence rates and pain relief. In the short term, quality of life (QoL) is restored by IHR. Two centers pioneered the IHR in Sweden with the highly standardized Rives–Stoppa technique using a retromuscular mesh. We assessed long-term follow-up of recurrence rate and QoL. Methods Medical records were searched for IHRs performed from 1998 to 2006 and included living patients with midline repairs. Questionnaires about physical status, complaints, and QoL (SF-36) were mailed, offering a clinical examination. Assessment of medical records of later surgery was performed in 2015. Results Three hundred and one patients with midline incisional repairs were identified, and 217 accepted participation. Of these, 103 attended a clinical examination. Follow-up was 7 years until examination and 11 years to reassessment of medical records. In 26%, recurrent hernias were repaired. Postoperative complications were 26% Clavien–Dindo grade I–II and 1% grade III–IV. Mesh infections occurred in 1.4% without mesh removals, and 4% were reoperated because of complications. Overall recurrence rate was 8.1% and two-third of which were diagnosed at clinical examination. Recurrence after primary and recurrent hernia repair was 7.1 and 10.9%, respectively. Of all patients, 80% were satisfied; dissatisfaction was primarily caused by recurrence and chronic pain. SF-36 scores were 0.2 SD lower than the norm in all subscales, similar to those with 1–2 chronic conditions. Conclusions Midline retromuscular mesh IHR has a low long-term recurrence rate even after recurrent repair. Patient satisfaction was high although QoL was reduced.

Introduction A laparotomy is commonly required to gain abdominal access. A safe standardized access and closure technique is warranted to minimize abdominal wall complications like wound infections, burst abdomen and incisional hernias. Stitches are recommended to be small and placed tightly, obtaining a suture length-to-incision length (SL/WL) ratio of ≥ 4:1. This can be time-consuming and difficult to achieve especially following long trying surgical procedures. The aim was to develop and evaluate a new mechanical suture device for standardized wound closure. Methods A mechanical suture device (Suture-tool) was developed in collaboration between a medical technology engineer team with the aim to achieve a standardized suture line of high quality that could be performed speedy and safe. Ten surgeons closed an incision in an animal tissue model after a standardized introduction of the instrument comparing the device to conventional needle driver suturing (NDS) using the 4:1 technique. Outcome measures were SL/WL ratio, number of stitches and suture time. Results In total, 80 suture lines were evaluated. SL/WL ratio of ≥ 4 was achieved in 95% using the Suture-tool and 30% using NDS ( p  < 0,001). Number of stitches was similar. Suture time was 30% shorter using the Suture-tool compared to NDS (2 min 54 s vs. 4 min 5 s; p  < 0.001). Conclusions The mechanical needle driver seems to be a promising device to perform a speedy standardized high-quality suture line for fascial closure.

Background Antibodies against gonadotropin-releasing hormone (GnRH) and gastrointestinal dysmotility have been found after treatment with GnRH analogues. The aim of this study was to examine the presence of such antibodies in patients with dysmotility not subjected to GnRH treatment and study the anti-GnRH antibody effect on enteric neurons viability in vitro . Methods Plasma and sera from 3 patients suffering from either enteric dysmotility, irritable bowel syndrome (IBS) or gastroparesis were analysed for C-reactive protein (CRP), and for GnRH antibodies and soluble CD40 by ELISA methods. Primary cultures of small intestinal myenteric neurons were prepared from rats. Neuronal survival was determined after the addition of sera either from the patients with dysmotility, from healthy blood donors, antiserum raised against GnRH or the GnRH analogue buserelin. Only for case 1 a full-thickness bowel wall biopsy was available for immunohistochemical analysis. Results All 3 patients expressed antibodies against GnRH. The antibody titer correlated to the levels of CD40 ( r s = 1.000, p < 0.01), but not to CRP. Serum from case 3 with highest anti-GnRH antibody titer, and serum concentrations of sCD40 and CRP, when added to cultured rat myenteric neurons caused remarkable cell death. In contrast, serum from cases 1 and 2 having lower anti-GnRH antibody titer and lower sCD40 levels had no significant effect. Importantly, commercial antibodies against GnRH showed no effect on neuron viability whereas buserelin exerted a protective effect. The full-thickness biopsy from the bowel wall of case 1 showed ganglioneuritis and decrease of GnRH and GnRH receptor. Conclusion Autoantibodies against GnRH can be detected independently on treatment of GnRH analogue. Whether the generation of the antibody is directly linked to neuron degeneration and chronic gastrointestinal symptoms in patients with intestinal dysmotility, remains to be answered.