International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair

[Robotic hernia repair : Part III: Robotic incisional hernia repair with transversus abdominis release (r-TAR). Video report and results of a cohort study]

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aKS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pKS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pKS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

Excess Body Weight and Abdominal Hernia

Background

Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI.

Summary

This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young.

Key Messages

Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

Perioperative optimization in complex abdominal wall hernias: Delphi consensus statement

BACKGROUND

The incidence of incisional hernia after major abdominal surgery via a midline laparotomy is 20-41 per cent with short-term follow-up, and over 50 per cent in those surviving an abdominal catastrophe. Abdominal wall reconstruction (AWR) requires complex operations, often involving mesh resection, management of scarred skin, fistula takedown, component separation or flap reconstruction. Patients tend to have more complex conditions, with multiple co-morbidities predisposing them to a vicious cycle of complications and, subsequently, hernia recurrence. Currently there appears to be variance in perioperative practice and minimal guidance globally. The aim of this Delphi consensus was to provide a clear benchmark of care for the preoperative assessment and perioperative optimization of patients undergoing AWR.

METHODS

The Delphi method was used to achieve consensus from invited experts in the field of AWR. Thirty-two hernia surgeons from recognized hernia societies globally took part. The process included two rounds of anonymous web-based voting with response analysis and formal feedback, concluding with a live round of voting followed by discussion at an international conference. Consensus for a strong recommendation was achieved with 80 per cent agreement, and a weak recommendation with 75 per cent agreement.

RESULTS

Consensus was obtained on 52 statements including surgical assessment, preoperative assessment, perioperative optimization, multidisciplinary team and decision-making, and quality-of-life assessment. Forty-six achieved over 80 per cent agreement; 14 statements achieved over 95 per cent agreement.

CONCLUSION

Clear consensus recommendations from a global group of experts in the AWR field are presented in this study. These should be used as a baseline for surgeons and centres managing abdominal wall hernias and performing complex AWR.

[Robotic hernia repair : Part II: Robotic primary ventral and incisional hernia repair (rv-TAPP and r-Rives or r-TARUP). Video report and results of a series of 118 patients]

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r‑ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r‑TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

Prophylactic negative pressure wound therapy after open ventral hernia repair: a systematic review and meta-analysis

PURPOSE

Negative pressure wound therapy on closed incisions (iNPWT) is a wound dressing system developed to promote wound healing and avoid complications after surgical procedures. The effect of iNPWT is well established in various surgical fields, however, the effect on postoperative wound complications after ventral hernia repair remains unknown. The aim of this systematic review and meta-analysis was to investigate the effect of iNPWT on patients undergoing open ventral hernia repair (VHR) compared with conventional wound dressing.

MATERIALS AND METHODS

This systematic review and meta-analysis followed the PRISMA guidelines. The databases PubMed, Embase, Cochrane Library, Web of science and Cinahl were searched for original studies comparing iNPWT to conventional wound dressing in patients undergoing VHR. The primary outcome was surgical site occurrence (SSO), secondary outcomes included surgical site infection (SSI) and hernia recurrence.

RESULTS

The literature search identified 373 studies of which 10 were included in the meta-analysis including a total of 1087 patients. Eight studies were retrospective cohort studies, one was a cross-sectional pilot study, and one was a randomized controlled trial. The meta-analysis demonstrated that iNPWT was associated with a decreased risk of SSO (OR 0.27 [0.19, 0.38]; P < 0.001) and SSI (OR 0.32 [0.17, 0.55]; P < 0.001). There was no statistically significant association with the risk of hernia recurrence (OR 0.62 [0.27, 1.43]; P = 0.26).

CONCLUSION

Based on the findings of this systematic review and meta-analysis iNPWT following VHR was found to significantly reduce the incidence of SSO and SSI, compared with standard wound dressing. INPWT should be considered for patients undergoing VHR.

Subxiphoid top-down endoscopic totally preperitoneal approach (eTPA) for midline ventral hernia repair

PURPOSE

Midline abdominal wall hernia repair is among the most common surgical interventions performed worldwide. However, the optimal surgical technique remains controversial. To overcome the disadvantages of both open and transabdominal procedures, we developed a totally endoscopic preperitoneal approach (eTPA) with placement of a large mesh.

METHODS

From December 2019 to October 2020, 20 consecutive patients with small to medium-sized midline ventral hernias underwent repair using a completely preperitoneal subxiphoid top-down approach. The preperitoneal space was entered directly below the xiphoid, and careful endoscopic development of the plane between the peritoneum and posterior sheath of the rectus fascia was then performed behind the linea alba. The hernia sac and its contents were identified and reduced. The hernia defect was closed with sutures, and a mesh with an adequate high defect: mesh ratio was placed in the newly created preperitoneal space.

RESULTS

Twenty patients were enrolled in this study, including 14 with primary umbilical hernias, 4 with primary epigastric hernias, and 2 with recurrent umbilical hernias. 15 patients suffered from a mild concomitant diastasis recti. All operations were successfully completed without conversion to open repair. The mean operative time was 105.3 min (range, 60-220 min). Postoperative pain was mild, and the mean visual analog scale score for pain was 1.8 on the first postoperative day. The average postoperative hospital stay was 1.8 days (range, 1-4 days). One patient developed a minor postoperative seroma, but it had no adverse impact on the final outcome. No patients developed recurrence during the 3- to 10-month follow-up period.

CONCLUSIONS

The subxiphoid top-down totally endoscopic preperitoneal approach (eTPA) technique is feasible and effective. It may become a valuable alternative for the treatment of primary small- (defect size < 2 cm) and medium-sized (2-4 cm) midline ventral hernias, particularly in presence of a concomitant diastasis recti.

Reporting guideline for interventional trials of primary and incisional ventral hernia repair

BACKGROUND

Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created.

METHODS

To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data.

RESULTS

The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected.

CONCLUSION

These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Wide variation in surgical techniques to repair incisional hernias: a survey of practice patterns among general surgeons

BACKGROUND

The purpose of this research was to examine the self-reported practice patterns of Canadian general surgeons regarding the elective repair of incisional hernias.

METHODS

A mail survey was sent to all general surgeons in Canada. Data were collected regarding surgeon training, years in practice, practice setting and management of incisional hernias. Surgeons were asked to describe their usual surgical approach for a patient with a midline incisional hernia and a 10 × 6 cm fascial defect.

RESULTS

Of the 1876 surveys mailed out 555 (30%) were returned and 483 surgeons indicated that they perform incisional hernia repair. The majority (62%) have been in practice > 10 years and 73% regularly repair incisional hernias. In response to the clinical scenario of a patient with an incisional hernia, 74% indicated that they would perform an open repair and 18% would perform a laparoscopic repair. Ninety eight percent of surgeons would use mesh, 73% would perform primary fascial closure and 47% would perform a component separation. The most common locations for mesh placement were intraperitoneal (46%) and retrorectus/preperitoneal (48%). The most common repair, which was reported by 37% of surgeons, was an open operation, with mesh, with primary fascial closure and a component separation.

CONCLUSIONS

While almost all surgeons who perform incisional hernia repairs would use permanent mesh, there was substantial variation reported in surgical approach, mesh location, fascial closure and use of component separation techniques. It is unclear how this variability may impact healthcare resources and patient outcomes.

Observational Cohort Study on the Use of a Slowly Fully Resorbable Synthetic Mesh (Phasix™) in the Treatment of Complex Abdominal Wall Pathology with Different Grades of Contamination

PURPOSE

Abdominal wall hernia repair in contaminated cases remains a therapeutic challenge due to the high risk of post-operative surgical site occurrences (SSO). Slowly resorbable synthetic (biosynthetic) meshes have recently been introduced and may offer unique advantages when challenged with bacterial colonization during abdominal wall reconstruction.

METHODS

A multicenter single-arm retrospective observational cohort study examined all consecutive patients in whom a poly-4-hydroxybutyrate mesh (Phasix™ or Phasix™ ST; Becton Dickinson, Franklin Lakes, NJ, USA) was used for the repair of an inguinal or ventral/incisional hernia, or to replace an infected synthetic mesh. Patient records were analyzed according to the level of contamination, using the classification score of the Centers for Disease Control and Prevention (CDC). The primary objective was to evaluate short-term postoperative morbidity by assessing SSOs and the need for reoperation or even mesh excision.

RESULTS

A total of 47 patients were included. The median age was 68 years (30-87), the male/female ratio was 26/21, and the median BMI was 26.5 kg/m2 (16.4-46.8). There were 17 clean cases, 17 clean-contaminated, 6 contaminated and 7 dirty. Median follow-up time was 48 days. An SSO was seen in 4 clean (23.5%), 7 clean-contaminated (41.2%), 2 contaminated (33.3%) and 5 dirty cases (71.4%). A surgical site occurrence requiring procedural intervention (SSOPI) was seen in 2 clean (11.8%), 3 clean-contaminated (17.6%), 1 contaminated (16.7%) and 2 dirty cases (28.6%). Hernia recurrence was seen in 1 clean (5.9%), 2 clean-contaminated (11.8%) and 3 dirty cases (42.9%). Mesh excision had to be performed in only one case in the contaminated group.

CONCLUSION

The Phasix™ mesh shows promising short-term results when used in contaminated hernia-related surgery. Even in contaminated or dirty conditions, with or without infection of the mesh, resection of the mesh only had to be performed once and patients could be managed either conservatively or by relatively minor reoperations. However, further research is needed to fully evaluate the safety and efficacy of these meshes.

Stepwise transversus abdominis muscle release for the treatment of complex bilateral subcostal incisional hernias

BACKGROUND

Management of subcostal incisional hernias is particularly complicated due to their proximity to the costochondral limits in addition to the lack of aponeurosis on the lateral side of the abdomen. We present our results of posterior component separation through the same previous incision as a safe and reproducible technique for these complex cases.

METHODS

We presented a multicenter and prospective cohort of patients diagnosed with bilateral subcostal incisional hernias on either clinical examination or imaging based on computed tomography from 2014 to 2020. The aim of this investigation was to assess the outcomes of abdominal wall reconstruction for subcostal incisional hernias through a new approach. The outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score.

RESULTS

A total of 46 patients were identified. All patients underwent posterior component separation. Surgical site occurrences occurred in 10 patients (22%), with only 7 patients (15%) requiring procedural intervention. During a mean follow-up of 18 months (range, 6-62 months), 1 (2%) case of clinical recurrence was registered. Also, there were 8 (17%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) of the postoperative scores compared with the preoperative score.

CONCLUSION

Posterior component separation technique for the repair of subcostal incisional hernias through the same incision is a safe procedure that avoids injury to the linea alba. It is associated with acceptable morbidity, low recurrence rate, and improvement in patients' reported outcomes.

Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study

BACKGROUND

Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies.

METHODS

This study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared.

RESULTS

From an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318-4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142-7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86-7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1-12.2; P = 0.001).

CONCLUSION

Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate.

TRIAL REGISTRATION

NCT04578561. www.clinicaltrials.gov.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

BACKGROUND

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined.

METHODS

This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations.

RESULTS

From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P  < 0.001). One patient in the mesh group required mesh removal because of deep infection.

CONCLUSION

Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

GRAPHICAL ABSTRACT

An RCT was conducted to compare the widely recommended midline laparotomy closure using a slowly absorbable running suture with closure using a sublay mesh (Parietex ProGrip™), in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Patients were followed up for 24 months with clinical and ultrasonographic evaluation during outpatient visits. Prophylactic reinforcement of the midline abdominal wall, using a ProGrip™ Parietex mesh in the retromuscular position, at the time of urgent laparotomy in clean-contaminated wounds was safe and effective in reducing the incidence of incisional hernia, although larger studies with longer follow-up are required.

An evaluation of clinical and quality of life outcomes after ventral hernia repair with poly-4-hydroxybutyrate mesh

PURPOSE

Despite continued efforts, recurrence after ventral hernia repair (VHR) remains a common problem. Biosynthetic Phasix^™ (Poly-4-Hydroxybutyrate, P4HB) mesh combines the durability of synthetic mesh with the bio-resistance of biologics. P4HB has shown promising early outcomes, but long-term data are lacking. We examine patients following VHR with P4HB with at least 3 years of follow-up to assess clinical and patient reported outcomes (PROs).

METHODS

Adult patients (≥ 18 years old) undergoing VHR with P4HB mesh between 10/2015 and 01/2018 by a single surgeon were retrospectively identified. Patients with < 36 months of follow-up were excluded unless they had a documented recurrence. Clinical outcomes and quality of life using the Hernia-Related Quality of Life Survey (HerQLes) were assessed.

RESULTS

Seventy-one patients were included with a median age and body mass index of 61.2 and 31 kg/m², respectively. Mesh was placed in the retromuscular (79%) and onlay (21%) planes with 1/3 of patients having hernias repaired in contaminated fields. There were no mesh infections, enterocutaneous fistulas, or mesh explantations. Nine patients (12.7%) developed recurrence at a median follow-up of 43.1 months [38.2-49.1]. Mesh plane, fixation technique, and Ventral Hernia Working Group were not associated with recurrence. Significant improvement in disease-specific PROs was observed and maintained at 3-year follow-up.

CONCLUSION

Longitudinal clinical and quality of life outcomes after clean and contaminated VHR with P4HB are limited. Here, we conclude that P4HB is an effective and versatile mesh option for use in abdominal wall reinforcement.

Peritoneal flap hernioplasty for repair of incisional hernias after orthotopic liver transplantation

Background

Repair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in the context of lifelong immunosuppression. The peritoneal flap hernioplasty addresses this problem by using flaps of the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space, exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. We report our short and long-term results of 26 consecutive liver transplant cases with incisional hernias undergoing repair with the peritoneal flap technique.

Methods

Post-OLT patients undergoing elective peritoneal flap hernioplasty for incisional hernias from Jan 1, 2010–Nov 1, 2017 were identified from the Lothian Surgical Audit system (LSA), a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in Feb 2020.

Results

A total of 517 liver transplantations were performed during the inclusion period. Twenty-six of these (18 males, 69%) developed an incisional hernia and underwent a peritoneal flap repair. Median mesh size (Optilene Elastic, 48 g/m², BBraun) was 900 cm² (range 225–1500 cm²). The median time to repair following OLT was 33 months (range 12–70 months). Median follow-up was 54 months (range 24–115 months) and median postoperative stay was 5 days (range 3–11 days). Altogether, three patients (12%) presented with postoperative complications: 1 with hematoma (4%) and two with chronic pain (8%). No episodes of infection or symptomatic seroma were recorded. No recurrence was recorded within the follow-up period.

Conclusion

Repair of incisional hernias in patients following liver transplantation with the Peritoneal Flap Hernioplasty is a safe procedure associated with few complications and a very low recurrence rate. We propose this technique for the reconstruction of incisional hernias following liver transplantation.

Identifying predictors of ventral hernia recurrence: systematic review and meta-analysis

BACKGROUND

Ventra hernias are increasing in prevalence and many recur despite attempted repair. To date, much of the literature is underpowered and divergent. As a result there is limited high quality evidence to inform surgeons succinctly which perioperative variables influence postoperative recurrence. This systematic review aimed to identify predictors of ventral hernia recurrence.

METHODS

PubMed was searched for studies reporting prognostic data of ventral hernia recurrence between 1 January 1995 and 1 January 2018. Extracted data described hernia type (primary/incisional), definitions of recurrence, methods used to detect recurrence, duration of follow-up, and co-morbidity. Data were extracted for all potential predictors, estimates and thresholds described. Random-effects meta-analysis was used. Bias was assessed with a modified PROBAST (Prediction model Risk Of Bias ASsessment Tool).

RESULTS

Screening of 18 214 abstracts yielded 274 individual studies for inclusion. Hernia recurrence was defined in 66 studies (24.1 per cent), using 41 different unstandardized definitions. Three patient variables (female sex, age 65 years or less, and BMI greater than 25, 30, 35 or 40 kg/m2), five patient co-morbidities (smoking, diabetes, chronic obstructive pulmonary disease, ASA grade III-IV, steroid use), two hernia-related variables (incisional/primary, recurrent/primary), six intraoperative variables (biological mesh, bridged repair, open versus laparoscopic surgery, suture versus mesh repair, onlay/retrorectus, intraperitoneal/retrorectus), and six postoperative variables (any complication, surgical-site occurrence, wound infection, seroma, haematoma, wound dehiscence) were identified as significant prognostic factors for hernia recurrence.

CONCLUSION

This study summarized the current evidence base for predicting ventral hernia recurrence. Results should inform best practice and future research.

A structured pathway for developing your complex abdominal hernia service: our York pathway

PURPOSE

Clinical pathways are widely prevalent in health care and may be associated with increased clinical efficacy, improved patient care, streamlining of services, while providing clarity on patient management. Such pathways are well established in several branches of healthcare services but, to the authors' knowledge, not in complex abdominal wall reconstruction (CAWR). A stepwise, structured and comprehensive approach to managing complex abdominal wall hernia (CAWH) patients, which has been successfully implemented in our practice, is presented.

METHODS

A literature search of common databases including Embase® and MEDLINE® for CAWH pathways identified no comprehensive pathway. We therefore undertook a reiterative process to develop the York Abdominal Wall Unit (YAWU) through examination of current evidence and logic to produce a pragmatic redesign of our own pathway. Having introduced our pathway, we then performed a retrospective analysis of the complexity and number of abdominal wall cases performed in our trust over time.

RESULTS

We describe our pathway and demonstrate that the percentage of cases and their complexity, as defined by the VHWG classification, have increased over time in York Abdominal Wall Unit.

CONCLUSION

A structured pathway for complex abdominal wall hernia service is one way to improve patient experience and streamline services. The relevance of pathways for the hernia surgeon is discussed alongside this pathway. This may provide a useful guide to those wishing to establish similar personalised pathways within their own units and allow them to expand their service.

The experimental methodology and comparators used for in vivo hernia mesh testing: a 10-year scoping review

PURPOSE

Before being marketed, hernia mesh must undergo in vivo testing, which often includes biomechanical and histological assessment. Currently, there are no universal standards for this testing and methods vary greatly within the literature. A scoping review of relevant studies was undertaken to analyse the methodologies used for in vivo mesh testing.

METHODS

Medline and Embase databases were searched for relevant studies. 513 articles were identified and 231 duplicates excluded. 126 papers were included after abstract and full text review. The data extraction was undertaken using standardised forms.

RESULTS

Mesh is most commonly tested in rats (53%). 78% of studies involve the formation of a defect; in 52% of which the fascia is not opposed. The most common hernia models use mesh to bridge an acute defect (50%). Tensile strength testing is the commonest form of mechanical testing (63%). Testing strip widths and test speeds vary greatly (4-30 mm and 1.625-240 mm/min, respectively). There is little consensus on which units to use for tensile strength testing. Collagen is assessed for its abundance (54 studies) more than its alignment (18 studies). Alignment is not measured quantitatively. At least 21 histological scoring systems are used for in vivo mesh testing.

CONCLUSIONS

The current practice of in vivo mesh testing lacks standardisation. There is significant inconsistency in every category of testing, both in methodology and comparators. We would call upon hernia organisations and materials testing institutions to discuss the need for a standardised approach to this field.

Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients

BACKGROUND

In recent decades, biologic mesh (BM) has become an important adjunct to surgical practice. Recent evidence-based clinical applications of BM include but are not limited to: reconstruction of abdominal wall defects; breast reconstruction; face, head and neck surgery; periodontal surgery; other hernia repairs (diaphragmatic, hiatal/paraesophageal, inguinal and perineal); hand surgery; and shoulder arthroplasty. Prior systematic reviews of BM in complex abdominal wall hernia repair had several shortcomings that our comprehensive review seeks to address, including exclusion of laparoscopic repair, assessment of risk of bias, use of an acceptable meta-analytic method and review of risk factors identified in multivariable regression analyses.

MATERIALS AND METHODS

We sought articles of BM for open ventral hernia repair reporting on early complications, late complications or recurrences and included minimum of 50. We used the quality in prognostic studies risk of bias assessment tool. Random effects meta-analysis was applied.

RESULTS

This comprehensive review selected 62 articles from 51 studies that included 6,079 patients. Meta-analytic pooling found that early complications are present in about 50%, surgical site occurrences (SSOs) in 37%, surgical site infections (SSIs) in 18%, reoperation in 7%, readmission in 20% and mortality in 3%. Meta-analytic estimates of late outcomes included overall complications (42%), SSOs (40%) and SSIs (22%). Specific SSOs included seroma (14%), hematoma (4%), abscess (10%), necrosis (5%), dehiscence (8%) and fistula formation (5%). Reoperation occurred in about 17%, mesh explantation in 9% and recurrence in 36%.

CONCLUSION

Estimates of nearly all outcomes from individual studies were highly heterogeneous and sensitivity analyses and meta-regressions generally failed to explain this heterogeneity. Recurrence is the only outcome for which there are consistent findings for risk factors. Bridge placement of BM is associated with higher risk of recurrence. Prior hernia repair, history of reintervention and history of mesh removal were also risk factors for increased recurrence.

Second Look After Retromuscular Repair With the Combination of Absorbable and Permanent Meshes

Objective: The aim of this study is to describe the macroscopic features and histologic details observed after retromuscular abdominal wall reconstruction with the combination of an absorbable mesh and a permanent mesh.

Methods: We have considered all patients that underwent abdominal wall reconstruction (AWR) with the combination of two meshes that required to be reoperated for any reason. Data was extracted from a prospective multicenter study from 2012 to 2019. Macroscopic evaluation of parietal adhesions and histological analysis were carried out in this group of patients.

Results: Among 466 patients with AWR, we identified 26 patients that underwent a reoperation after abdominal wall reconstruction using absorbable and permanent mesh. In eight patients, the reoperation was related to abdominal wall issues: four patients were reoperated due to recurrence, three patients required an operation for chronic mesh infection and one patient for symptomatic bulging. A miscellanea of pathologies was the cause for reoperation in 18 patients. During the second surgical procedures made after a minimum of 3 months follow-up, a fibrous tissue between the permanent mesh covering and protecting the peritoneum was identified. This fibrous tissue facilitated blunt dissection between the permanent material and the peritoneum. Samples of this tissue were obtained for histological examination. No case of severe adhesions to the abdominal wall was seen. In four cases, the reoperation could be carried out laparoscopically with minimal adhesions from the previous procedure.

Conclusions: The reoperations performed after the combination of absorbable and permanent meshes have shown that the absorbable mesh acts as a protective barrier and is replaced by a fibrous layer rich in collagen. In the cases requiring new hernia repair, the layer between peritoneum and permanent mesh could be dissected without special difficulty. Few intraperitoneal adhesions to the abdominal wall were observed, mainly filmy, easy to detach, facilitating reoperations.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Recurrent incisional hernia repair: surgical outcomes in correlation with body-mass index

BACKGROUND

Hernia recurrence rates after incisional hernia repair vary between 8.7 and 32%, depending on multiple factors such as patient characteristics, the use of meshes, surgical technique and the degree of experience of the treating surgeon. Recurrent hernias are considered complex wall hernias, and 20% of all incisional hernia repairs involve a recurrent hernia. The aim of this study was to investigate the outcomes after recurrent incisional hernia repair, in association with surgical technique and body-mass index (BMI).

METHODS

All patients who had incisional hernia repair between 2013 and 2018 were included. Primary outcome was rate of recurrent incisional hernia after initial hernia repair. Secondary outcomes were complication rate and recurrence rate in association with BMI.

RESULTS

A number of 269 patients were included, of which 75 patients (27.9%) with a recurrent incisional hernia. Recurrent hernia repair was performed in 49 patients, 83.7% underwent open repair. Complication rate for recurrent hernia repair was higher than for the initial incisional hernia repair. Of the 49 patients with recurrent hernia repair, patients with a BMI above 30 had higher complication and recurrence rates compared to patients with BMI below 30. Especially infectious complications were more common in patients with a higher BMI: 23.1% vs. 0% wound infections.

CONCLUSION

The results from this study show that complication and recurrence rates are increased after recurrent incisional hernia repair, which are further increased by obesity. Only a limited amount of literature is available on this topic, further larger multicenter studies are necessary, until then a patient-specific surgical approach based on the surgeon's expertise is recommended.

Surgical Site Infection: The Scourge of Abdominal Wall Reconstruction

Background: Surgical site infection (SSI) is a well-recognized and potentially catastrophic complication of abdominal wall reconstruction (AWR). The authors present a review of the literature surrounding SSI in AWR, exploring prevention and treatment strategies as well as risk factors. Methods: A comprehensive review of the current literature was undertaken. Evidence was reviewed and summarized with particular focus on prevention and treatment strategies available to hernia surgeons. Results: Patient risk factors for SSI are well described in the literature and include obesity, smoking, and other comorbidities. Contaminated hernias and cases involving enterocutaneous fistulae are also at higher risk of SSI. Surgical decisions such as type of mesh, plane of mesh placement, and fascial release may all contribute to SSI risk. To treat established mesh infection, conservative management with antibiotic agents and negative pressure therapy is a reasonable option in some cases. Removal of prosthesis appears to provide favorable results, however, repeat surgery can be problematic Conclusions: Surgical site infection remains an important pathology in the world of AWR. Surgeons have a wealth of tools in their arsenal to prevent and treat SSI and should be aware of the emerging evidence in the fast-moving specialty of hernia surgery. Complex cases should be handled by surgeons and centers with expertise in treating such patients.

The current state of robotic retromuscular repairs-a qualitative review of the literature

BACKGROUND

The management of ventral incisional hernias (VIH) has undergone many iterations over the last 5 years due to evolution in surgical techniques and advancement in robotic surgery. Four general principles have emerged: mesh usage, retromuscular mesh placement, primary fascial closure, and usage of minimally invasive techniques when possible. The application of robotic retromuscular repairs in VIH allow these principles to be applied simultaneously. This qualitative review attempts to answer what robotic retromuscular repairs are described, which patients are selected for these techniques, and what are current outcomes.

METHODS

Using the key words: "robotic retromuscular repair", "robotic Rives Stoppa", and "robotic transversus abdominis release", a PubMed search of articles written up to December 2019 was critically reviewed.

RESULTS

44 articles were encountered, 9 high-quality articles were analyzed for this manuscript. Level of evidence ranged from 2B to 2C. Robotic TAR patients had BMI of 33 kg/m², defect sizes ranging from 7-14 cm wide to 12-19 cm long, longer OR times, no difference in surgical site events, and shorter length of stay (LOS). The techniques to perform robotic Rives Stoppa (RS) were heterogeneous; however, extended totally extraperitoneal (ETEP) approach is most described. Defect width for RS repairs ranged 4-7 cm and LOS was less than 1 day. Complication rates were low, there is no long-term data on hernia recurrence, and information on cost is limited.

CONCLUSION

In short-term follow-up, robotic retromuscular repairs show promise that VIH can be repaired with intramuscular mesh, few complications, and shorter LOS. Data on hernia recurrence, long-term complications, and rigorous cost analysis are needed to demonstrate generalizability.

Outcomes of surgically managed recurrent parastomal hernia: the Sisyphean challenge of the hernia world

PURPOSE

The management of a recurrent (symptomatic) parastomal hernia (PSH) presents a dilemma. The aim of this study was to review the outcome of patients who underwent a recurrent PSH repair.

METHODS

Retrospective review of consecutive patients undergoing recurrent PSH repairs at a single institution between 2010 and 2019. Primary outcome recorded was recurrence. Secondary outcomes recorded were 30-day post-operative complications, surgical site occurrence (SSO) incidence and to assess if EHS classification altered with each recurrence.

RESULTS

Thirty-eight patients underwent 59 recurrent PSH repairs during the study period. Median number of PSH repairs per patient from ostomy formation was 2 (2-8). Post-operative complications occurred following 52.5% of repairs. Recurrence rate for all recurrent PSH hernia repairs was 45.7%, with a median follow-up of 58 months (0-115). A trend was seen towards a shorter PSH recurrence-free survival in those who had at least two previous PSH repairs at the start of the study period when compared to those who had less. Recurrence was not associated with operative urgency, type of repair, mesh type or SSO occurrence. A significant decrease in recurrence was seen with retro-rectus mesh placement when compared to onlay (p = 0.003). EHS classification did not change between each recurrence in 70.8% of patients.

CONCLUSION

Recurrence rates after recurrent PSH repair are high. The recurrence-free survival was worse after the second or more attempt at repair for recurrence. Further studies are warranted to explore prophylaxis, optimal repair method, and where re-recurrence occurs, the benefit of repeated surgical intervention.