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Importance Although multiple versions of polypropylene mesh devices are currently available on the market for hernia repair, few comparisons exist to guide surgeons as to which device may be preferable for certain indications. Mesh density is believed to impact patient outcomes, including rates of chronic pain and perception of mesh in the abdominal wall. Objective To examine whether medium-weight polypropylene is associated with less pain at 1 year compared with heavy-weight mesh. Design, setting, and participants This multicenter randomized clinical trial was performed from March 14, 2017, to April 17, 2019, with 1-year follow-up. Patients undergoing clean, open ventral hernia repairs with a width 20 cm or less were studied. Patients were blinded to the intervention. Interventions Patients were randomized to receive medium-weight or heavy-weight polypropylene mesh during open ventral hernia repair. Main outcomes and measures The primary outcome was pain measured with the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Short Form 3a. Secondary outcomes included quality of life and pain measured at 30 days, quality of life measured at 1 year, 30-day postoperative morbidity, and 1-year hernia recurrence. Results A total of 350 patients participated in the study, with 173 randomized to receive heavy-weight polypropylene mesh (84 [48.6%] female; mean [SD] age, 59.2 [11.4] years) and 177 randomized to receive medium-weight polypropylene mesh (91 [51.4%] female; mean [SD] age, 59.3 [11.4] years). No significant differences were found in demographic characteristics (mean [SD] body mass index of 32.0 [5.4] in both groups [calculated as weight in kilograms divided by height in meters squared] and American Society of Anesthesiologists classes of 2-4 in both groups), comorbidities (122 [70.5%] vs 93 [52.5%] with hypertension, 44 [25.4%] vs 43 [24.3%] with diabetes, 17 [9.8%] vs 12 [6.8%] with chronic obstructive pulmonary disease), or operative characteristics (modified hernia grade of 2 in 130 [75.1] vs 140 [79.1] in the heavy-weight vs medium-weight mesh groups). Pain scores for patients in the heavy-weight vs medium-weight mesh groups at 30 days (46.3 vs 46.3, P = .89) and 1 year (30.7 vs 30.7, P = .59) were identical. No significant differences in quality of life (median [interquartile range] hernia-specific quality of life score at 1 year of 90.0 [67.9-96.7] vs 86.7 [65.0-93.3]; median [interquartile range] hernia-specific quality of life score at 30 days, 45.0 [24.6-73.8] vs 43.3 [28.3-65.0]) were found for the heavy-weight mesh vs medium-weight mesh groups. Composite 1-year recurrence rates for patients in the heavy-weight vs medium-weight polypropylene groups were similar (8% vs 7%, P = .79). Conclusions and relevance Medium-weight polypropylene did not demonstrate any patient-perceived or clinical benefit over heavy-weight polypropylene after open retromuscular ventral hernia repair. Long-term follow-up of these comparable groups will elucidate any potential differences in durability that have yet to be identified. Trial registration ClinicalTrials.gov Identifier: NCT03082391.

IMPORTANCE: Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients’ electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice. OBJECTIVE: To determine how wound photography affects surgeons’ abilities to diagnose SSIs in a pragmatic setting. DESIGN, SETTING, AND PARTICIPANTS: This prospective study compared surgeons’ paired assessments of postabdominal surgery case vignettes with vs without wound photography for detection of SSIs. Data for case vignettes were collected prospectively from May 1, 2007, to January 31, 2009, at Erasmus University Medical Center, Rotterdam, the Netherlands, and from July 1, 2015, to February 29, 2016, at Vanderbilt University Medical Center, Nashville, Tennessee. The surgeons were members of the American Medical Association whose self-designated specialty is general, abdominal, colorectal, oncologic, or vascular surgery and who completed internet-based assessments from May 21 to June 10, 2016. INTERVENTION: Surgeons reviewed online clinical vignettes with or without wound photography. MAIN OUTCOMES AND MEASURES: Surgeons’ diagnostic accuracy, sensitivity, specificity, confidence, and proposed management with respect to SSIs. RESULTS: A total of 523 surgeons (113 women and 410 men; mean [SD] age, 53 [10] years) completed a mean of 2.9 clinical vignettes. For the diagnosis of SSIs, the addition of wound photography did not change accuracy (863 of 1512 [57.1%] without and 878 of 1512 [58.1%] with photographs). Photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63). In 415 of 1512 cases (27.4%), the addition of wound photography changed the surgeons’ assessment (215 of 1512 [14.2%] changed from incorrect to correct and 200 of 1512 [13.2%] changed from correct to incorrect). Surgeons reported greater confidence when vignettes included a wound photograph compared with vignettes without a wound photograph, regardless of whether they correctly identified an SSI (median, 8 [interquartile range, 6-9] vs median, 8 [interquartile range, 7-9]; P

Importance Maintaining perioperative normothermia has been shown to decrease the rate of surgical site infection (SSI) after segmental colectomy and is part of the World Health Organization’s Guidelines for Safe Surgery. However, strong evidence supporting this association is lacking, and an exact definition of normothermia has not been described. Objective To determine whether intraoperative hypothermia in patients who undergo segmental colectomy is associated with postoperative SSI. Design, Setting, and Participants In a retrospective cohort study at a single tertiary-referral hospital, 296 adult patients who underwent elective segmental colectomy from January 1, 2005, through December 31, 2009, were included. Exclusion criteria included postoperative stoma, emergent or urgent operation, and diagnosis of inflammatory bowel disease. Exposures Perioperative temperature was measured continuously, and 4 possible definitions of hypothermia were explored, including temperature nadir, mean intraoperative temperature, percentage of time at the temperature nadir, and percentage of time with a temperature of less than 36.0°C. Main Outcomes and Measures The primary outcome measure was 30-day SSI. Secondary outcome measures included clinical leak, return to the operating room, and nasogastric tube placement (a surrogate for ileus). Results The mean (SD) findings were as follows: intraoperative temperature, 35.9°C (0.6°C); temperature nadir, 34.3°C (2.8°C); percentage of time at the nadir, 4.7% (10.8%); and percentage of time with a temperature of less than 36.0°C, 49.9% (42.0%). The rate of SSI was 12.2% (n = 36). There was no statistically significant difference in temperature measurements between the patients who developed an SSI and those who did not. Logistic regression models evaluated each exposure measure and its effect on SSI, adjusting for body mass index, smoking status, and sex. The adjusted analyses revealed no association between intraoperative hypothermia and 30-day SSI (odds ratio, 1.17; 95% CI, 0.76-1.81; P = .48). Increased body mass index (odds ratio, 1.39; 95% CI, 1.10-1.76; P = .007) was significantly associated with SSI in all 4 logistic regression models. Conclusions and Relevance Patients who underwent segmental colectomy and sustained a period of intraoperative hypothermia were no more likely to develop an SSI than those who were normothermic.

Importance Previous work has demonstrated that dynamic abdominal sonography for hernia (DASH) is accurate for the diagnosis of incisional hernia. The usefulness of DASH for characterization of incisional hernia is unknown. Objective To determine whether DASH can be objectively used to characterize incisional hernias by measurement of mean surface area (MSA). Design, Setting, and Participants A prospective cohort study was conducted. A total of 109 adults with incisional hernia were enrolled between July 1, 2010, and March 1, 2012. Patients with a stoma, fistula, or soft-tissue infection were excluded. Interventions DASH was performed by a surgeon to determine the maximal transverse and craniocaudal dimensions of the incisional hernia. A separate surgeon, blinded to the DASH results, performed the same measurements using computed tomography (CT). Main Outcomes and Measures The MSA was calculated, and the difference in MSA by DASH and CT was compared using the Wilcoxon signed rank test. Subset analysis was performed with patients stratified into nonobese, obese, and morbidly obese groups. We hypothesized that there was no significant difference between MSA as measured by DASH compared with CT. Results A total of 109 patients were enrolled (mean age, 56 years; mean body mass index, 32.2 [calculated as weight in kilograms divided by height in meters squared]; and 67.0% women). The mean (SD) MSA measurements were similar between the modalities: DASH, 41.8 (67.5) cm 2 and CT, 44.6 (78.4) cm 2 ( P = .82). The MSA measurements determined by DASH and CT were also similar for all groups when stratified by body mass index. There were 15 patients who had a hernia 10 cm or larger in transverse dimension. The mean body mass index of this group was 39.2, and the MSA measurements by DASH and CT were similar ( P = .26). Conclusions and Relevance DASH can be used to objectively characterize hernias by MSA, with accuracy demonstrated in the obese population and in patients whose hernias were very large (≥10 cm in diameter). DASH offers the advantages of real-time imaging and no ionizing radiation and may obviate the need for the patient to schedule additional imaging appointments.