analysed separately in the subgroup analysis. No subgroup effects were identified in logistic regression analysis to adjust for these cofactors or other predisposing risk factors. Results from our follow-up of clinical and radiological examination showed a 23% incidence of incisional hernia in the control group at 1 year follow-up. Because diagnosis of incisional hernia was done by radiological examination, small, asymptomatic incisional hernias are thought to have been diagnosed, which might not have been detected by physical examination. The incidence rate of incisional hernia at 1 year follow-up in our study is comparable to that of randomised clinical trials6,7 with up to 3 years of follow-up using ultrasound for the diagnosis of incisional hernia. We declare no competing interests.

*Joris J Harlaar, Eva B Deerenberg, Johannes Jeekel, Johan F Lange [email protected] Department of Surgery, Erasmus University Medical Center Rotterdam, 3000 CA Rotterdam, Netherlands (JJH, EBD, JFL); and Department of Neuroscience, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands (JJ) 1


Published Online January 19, 2016 S0140-6736(16)00142-2



5 Published Online December 21, 2015 S0140-6736(15)01306-9




Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet 2015; 386: 1254–60. Seiler CM, Bruckner T, Diener MK, et al. Interrupted or continuous slowly absorbable sutures for primary closure of elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg 2009; 249: 576–82. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015; 19: 1–24. Diener MK, Voss S, Jensen K, Buchler MW, Seiler CM. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg 2010; 251: 843–56. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg 2009; 144: 1056–59. Bloemen A, van Dooren P, Huizinga BF, Hoofwijk AG. Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure. Br J Surg 2011; 98: 633–39. Fink C, Baumann P, Wente MN, et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg 2014; 101: 51–54.

Sign of the times: be careful what you say in the operating room While performing the last safety checks on pressure points of our anaesthetised patient for a major procedure requiring complex positioning, the anaesthetist noticed a small object tucked underneath the patient’s compression stockings. Initially it looked like a portable flash drive, but closer inspection revealed tiny printed letters spelling “mic”, a small red light, and a tiny switch which was turned on. It took a few moments for the realisation of what this device was and its intended purpose to dawn on us. Putting aside the inappropriateness of a concealed recording device in this setting, this situation raised several major concerns. First, there is the paramount issue of patient safety, with potential for pressure sore development, diathermy burns, and interference with monitoring equipment. Second, the equally key issue of patient confidentiality, because the device might have inadvertently recorded medical staff discussions regarding other patients, making the circumstances in theatre distinct from doctor–patient consultations in the clinic. The third point of concern is that comments made by theatre staff might be misinterpreted and taken out of context, or in the worse-case scenario, be used to instigate proceedings for damages or even for a claim of awareness during anaesthesia. We will never know the real intention of a covert recording. We refer to the recent court case in Virginia, USA, where a patient accidentally recorded on his smart phone derogatory remarks made by his anaesthesiologist and medical-care team while he was anaesthetised for his colonoscopy.1 The patient was awarded US$500 000 for defamation and medical malpractice. A simple internet search shows that a plethora of sophisticated recording devices are widely available.

The overwhelming feeling in the theatre room after the discovery was of violation and sadness with the acknowledgment that the sanctity of the doctor–patient relationship is threatened and weakened by rare incidences such as these. So it is a sign of the times, and having reflected on the circumstances around this event, we would like to advise all our colleagues to exercise caution; to ask patients at the pre-op check to, not only remove jewellery and metal, but also recording devices, and to explain the rationale behind the request, and finally, to be very careful what you say in the operating room. We declare no competing interests.

*Maxine G B Tran, Sergey Tadtayev, Thomas Palmer, Ailsa Evans, Faiz Mumtaz [email protected] The Renal Cancer Center, Royal Free Hospital, Pond Street, London NW3 2QG, UK 1

Jackman T. Man who recorded doctors mocking him during an operation sues anesthesiologist and practice for $500,000. The Independent. June 24, 2015: http://www. man-who-recorded-doctors-mocking-himduring-operation-sues-anesthesiologist-andpractice-for-500000-10341565.html (accessed Nov 25, 2015).

Department of Error The Lancet. Obesity: we need to move beyond sugar. Lancet 2016; 387: 199—In this Editorial (Jan 16), this sentence should have read “And the estimated number of people living with diabetes in the UK has topped 4 million for the first time, an increase of 119 965 compared with the previous year, and a rise of 65% during the past decade.” This correction has been made to the online version as of January 19, 2016. Wang-Gillam A, Li C-P, Bodoky G, et al, for the NAPOLI-1 Study Group. Nanoliposomal irinotecan with fluorouracil and folinic acid in metastatic pancreatic cancer after previous gemcitabinebased therapy (NAPOLI-1): a global, randomised, open-label, phase 3 trial. Lancet 2015; 387: 545–57—In this Article, in figure 2B, the number at risk for nanoliposomal irinotecan monotherapy at 6 months should be “53”. This correction has been made to the online version as of Dec 21, and the printed Article is correct. Vol 387 February 6, 2016

Sign of the times: be careful what you say in the operating room.

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