Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

Epigastric hernias in children and the use of ultrasound in its diagnosis

Introduction

There is a paucity of clinical data on pediatric epigastric hernias despite them accounting for up to 6% of all hernia repairs in children. We aimed to provide additional data to supplement those 117 cases of a recent systematic review and to further clarify the role of ultrasound in diagnosing pediatric epigastric hernia.

Methods

We retrospectively included all 60 patients treated for epigastric hernias in children in two tertiary pediatric surgical departments within 12 years. Associations were tested via point-biserial correlation analyses.

Results

Epigastric hernias primarily affected preschool children with a median age of 39 months. The vast majority of patients (88%) presented with swelling that was occasionally (30%) accompanied by pain. Fascial defects could be found during clinical examination in 45% of patients with a median size of 5 mm (95% CI 3 to 10). Smaller defects were less likely to be palpable (r=−0.44, 95% CI −0.08 to −0.7, p=0.021). Likewise, ultrasound was used more frequently with smaller fascial defect sizes (r=−0.51, 95% CI −0.16 to −0.74, p=0.007). Laparoscopic repair was used in 11 patients (19%) and more often (4/11) in combination with another simultaneous procedure than open repair (11/48).

Conclusions

Epigastric hernias are primarily a condition of the preschool child. Ultrasound can be beneficial if the diagnosis cannot be made clinically; otherwise, it is abdicable if it does not change the management of the patient’s epigastric hernia. Laparoscopic repairs might be beneficial for children with multiple defects or simultaneous procedures.

Emergency hernia repair: a retrospective cross-sectional study on the treatment modalities and adherence to guidelines in a tertiary public hospital

BACKGROUND

Emergency presentations of hernias can pose significant morbidity. In addition, providing optimal surgical intervention can be challenging due to patient and disease factors with multiple treatment modalities available. Recently there have been several guidelines written to help standardize practices in hernia management. The aim of our study was to review emergency hernia operations at our tertiary level teaching hospital, the method of repair and how this matched to international guidelines.

METHODS

We performed a retrospective chart review of all the patients who underwent emergency hernia surgery for strangulated/incarcerated hernias in our department over a 3-year period. Adherence to guidelines was assessed looking at appropriateness of mesh utilization, as well as the appropriateness of antibiotic usage.

RESULTS

A total of 184 cases from April 1st 2018 to March 31st 2021 were included. Of these hernias 12% contained necrotic or perforated bowel, 42% contained viable incarcerated bowel, and 45% contained just incarcerated fat. The compliance to the appropriate use of mesh overall was 85%, with a variation by hernia type. The global compliance to appropriate antibiotic therapy was high, at 89.7%. With antibiotic use compliance being very high in clean wounds (95.6%), and dirty wounds (100%). But lower in clean/contaminated or contaminated wounds (36.8%).

CONCLUSION

Compliance at our hospital was globally good. Areas of decreased compliance seem to be mostly regarding mesh use and antibiotic use in potentially contaminated fields and the concept of risk of bacterial translocation versus actual contamination, as well as in mesh use in smaller umbilical hernias.

Component Separation: A Case Report of Hybrid and Synthetic Absorbable Mesh Use for Complex Large Ventral Hernia Reparation

Ventral abdominal hernias are a common abdominal wall defect in the United States. We present a 50-year-old Caucasian male with a large (>18 cm) abdominal wall defect. An extensive complex abdominal wall reconstruction with advanced bilateral fascial flaps/component separation and repair of the abdominal wall defect was planned to restore the appropriate abdominal wall anatomic contour. The use of double mesh in large abdominal wall defects is still a relatively new documented technique. Only two case series detail the same technique used on this patient, with no articles on using a hybrid mesh with a synthetic absorbable mesh. This case uses an underlay and onlay mesh technique, with a hybrid mesh, Tela Biologics (Malvern, PA, USA), under the muscle, in this case, intraperitoneal bridging the gap. The anterior rectus sheath was reinforced with intercepted 0-Ethibond sutures (Ethicon/J&J, Bridgewater, NJ, USA) and then reinforced with a synthetic absorbable mesh (Phasix^TM, Becton Dickinson, Franklin Lakes, NJ). The outcome with this patient shows more research should be conducted on considering long-term results with the types of mesh and the question of whether there are additional benefits when using two different types of mesh and their placement in the sandwich technique.

Prospective cohort study on mesh shrinkage measured with MRI after robot-assisted minimal invasive retrorectus ventral hernia repair using an iron-oxide-loaded polyvinylidene fluoride mesh

BACKGROUND

Mesh-reinforced ventral hernia repair is considered the gold standard treatment for all but the smallest of hernias. Human data on mesh shrinkage in the retrorectus mesh position is lacking. A prospective observational cohort study was performed to measure mesh shrinkage in robot-assisted minimal invasive retrorectus repair of ventral hernias.

METHODS

A cohort of 20 patients underwent a robot-assisted minimal invasive retrorectus repair of their ventral hernia. Magnetic resonance imaging (MRI) imaging was performed one month and thirteen months after implantation of an iron-oxide-impregnated polyvinylidene fluoride (PVDF) mesh to assess the decrease in mesh surface area. Inter-rater reliability among three radiologists regarding measurement of the mesh dimensions was analyzed. Quality of Life scoring was evaluated.

RESULTS

The inter-rater reliability between the radiologists reported as the intra-class correlations proved to be excellent for mesh width (ICC 0.95), length (ICC 0.98) and surface area (ICC 0.99). Between MRI measurements at one month and thirteen months postoperatively, there was a significant increase in mesh surface area (+ 12.0 cm², p = 0.0013) and mesh width (+ 0.8 cm, p < 0.001), while the length of the mesh remained unchanged (-0.1 cm, p = 0.754). Quality of Life Scoring showed a significant improvement in Quality of Life after one month and a further improvement at thirteen months (p < 0.001).

CONCLUSION

There was an excellent inter-rater reliability between three radiologists when measuring width, length, and surface area of an iron-oxide-impregnated PVDF mesh using MRI visualization. Mesh shrinkage was not observed, instead the effective mesh surface area and width of the mesh increased.

Ventral hernia repair with enhanced-view totally extraperitoneal technique after a massive weight loss by laparoscopic sleeve gastrectomy

BACKGROUND

Ventral hernia repair (VHR) for obese patients is often associated with an increased risk of postoperative complications and hernia recurrences. Achieving preoperative weight loss is ideal before VHR; however, it is difficult to attain with medical treatment. Metabolic and bariatric surgery (MBS) offers the most effective and durable treatment for obesity. Therefore, massive weight loss occurring after MBS will improve the outcome of VHR.

CASE PRESENTATION

A 49-year-old man (122.9 kg, BMI 39.1 kg/m²) presented to our hospital wishing to undergo laparoscopic sleeve gastrectomy and VHR. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height. As the hernia orifice was large, mesh reinforcement was essential. We planned for him to undergo VHR after massive weight loss was achieved by MBS. VHR was performed using the enhanced-view totally extraperitoneal (eTEP) technique after weight loss of 38 kg was achieved 9 months following laparoscopic sleeve gastrectomy. His postoperative course was uneventful, and neither recurrence nor seroma was observed at 1 year follow-up.

CONCLUSIONS

eTEP repair of a ventral hernia after massive weight loss following MBS would appear to be the best combination treatment for obese patients with ventral hernias. However, long-term follow-up is necessary to establish its safety and efficacy.

Laparoscopic Intraperitoneal Onlay Mesh (IPOM): Short- and Long-Term Results in a Single Center

The laparoscopic intraperitoneal onlay mesh repair (IPOM) approach has become the most widely adopted technique in the last decade. The role of laparoscopic IPOM in the last years has been resizing due to several limitations. The aim of the present study is to evaluate short- and long-term outcomes in patients who underwent laparoscopic IPOM. This retrospective single-center study describes 170 patients who underwent laparoscopic IPOM for ventral hernia at the General Surgery Unit of Parma University Hospital from 1 January 2016 to 31 December 2020. We evaluated patient, hernia, surgical and postoperative characteristics. According to the defect size, we divided the patients into Group 1 (Ø < 30 mm), Group 2 (30 < Ø < 50 mm) and Group 3 (Ø > 50 mm). A total of 167 patients were included. The mean defect diameter was 41.1 ± 16.3 mm. The mean operative time was different among the three groups (p < 0.001). Higher Charlson Comorbidity Index, obesity and incisional hernia were related to postoperative seroma and obesity alone with SSO. p < 0.001 Recurrence was significantly higher in larger defects (Group 3) and incisional hernia. p < 0.001. This retrospective study suggests that laparoscopic IPOM is a feasible and safe surgical technique with an acceptable complication rate, especially in the treatment of smaller defects up to 5 cm.

Less postoperative pain and shorter length of stay after robot-assisted retrorectus hernia repair (rRetrorectus) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM) for small or medium-sized ventral hernias

BACKGROUND

The optimal repair of ventral hernia remains unknown. We aimed to evaluate the results after robotic-assisted laparoscopic transabdominal repair with retrorectus mesh placement (rRetrorectus) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM) for patients with small- or medium-sized ventral hernia.

METHODS

This was a retrospective cohort study of consecutive patients undergoing elective rRetrorectus or IPOM repair for small or medium-sized primary ventral or incisional hernias. The primary outcome was the postoperative need for transverse abdominis plane (TAP) block or epidural analgesia, secondary outcomes were length of stay and postoperative complications. All patients were followed for 30 days postoperatively.

RESULTS

A total of 59 patients were included undergoing rRetrorectus (n = 27) and IPOM (n = 32). Patients in the two groups were comparable in terms of age, sex, comorbidities, smoking status, body mass index (BMI), and type of hernia. The median fascial defect area was slightly larger in the rRetrorectus group (9 cm² vs. 6.2 cm², P = 0.031). The duration of surgery was longer for rRetrorectus (median 117.2 min. vs. 84.4, P = 0.003), whereas the postoperative need for TAP block or epidural analgesia was less after rRetrorectus compared with IPOM (3.7% versus 43.7%, P = 0.002). There were no severe complications or reoperations after either procedure. The length of stay was shorter after rRetrorectus (median 0 vs. 1 day, P < 0.001).

CONCLUSIONS

rRetrorectus was associated with reduced postoperative analgesic requirement and shorter length of stay compared with laparoscopic IPOM. Registration Clinicaltrial.gov: NCT05320055.

Hospital-level variation in mesh use for ventral and incisional hernia repair

BACKGROUND

Placement of prosthetic mesh during ventral and incisional hernia repair has been shown to reduce the incidence of postoperative hernia recurrence. Consequently, multiple consensus guidelines recommend the use of mesh for ventral hernias of any size. However, the extent to which real-world practice patterns reflect these recommendations is unclear.

METHODS

We performed a retrospective review of the Michigan Surgical Quality Collaborative Hernia Registry (MSQC-HR) to identify patients undergoing clean ventral or incisional hernia repair between January 1, 2020 and December 31, 2021. The primary outcome was mesh use. We used two-step hierarchical logistic regression modeling with empirical Bayes estimates to evaluate the association of hospital-level mesh use with patient, operative, and hernia characteristics.

RESULTS

A total of 5262 patients underwent ventral and incisional hernia repair at 65 hospitals with a mean age of 53.8 (14.5) years, 2292 (43.6%) females, and a mean hernia width of 3.2 (3.4) cm. Mean hospital volume was 81 (49) cases. Mesh was used in 4098 (77.9%) patients. At the patient level, hernia width and surgical approach were significantly associated with mesh use. Specifically, mesh use was 6.2% (95% CI 4.8-7.5%) more likely with each additional centimeter of hernia width and 28.0% (95% CI 26.1-29.8%) more likely for minimally invasive repair compared to open repair. At the hospital level, there was wide variation in mesh use, ranging from 38.0% (95% CI 31.5-44.9%) to 96.4% (95% CI 95.3-97.2%). Hospital-level mesh use was not associated with differences in hernia size (β =  - 0.003, P = 0.978), surgical approach (β =  - 1.109, P = 0.414), or any other patient factors.

CONCLUSIONS

Despite strong evidence supporting the use of mesh in ventral and incisional hernia repair, there is substantial variation in mesh use between hospitals that is not explained by differences in patient characteristics or operative approach. This suggests that opportunities exist to standardize surgical practice to better align with evidence supporting the use of mesh in the management of these hernias.

Impact of COVID-19 on volume of elective and nonelective ventral hernia repair

BACKGROUND

The significant decrease in elective surgery during the COVID-19 pandemic prompted fears that there would be an increase in emergency or urgent operations for certain disease states. The impact of COVID-19 on ventral hernia repair is unknown. This study aimed to compare volumes of elective and nonelective ventral hernia repairs performed pre-COVID-19 with those performed during the COVID-19 pandemic.

METHODS

An analysis of a prospective database from 8 hospitals capturing patient admissions with the International Classification of Diseases, Tenth Revision Procedure Coding System for ventral hernia repair from January 2017 through June 2021 were included. During, COVID-19 was defined as on or after March 2020.

RESULTS

Comparing 3,558 ventral hernia repairs pre-COVID-19 with 1,228 during COVID-19, there was a significant decrease in the mean number of elective ventral hernia repairs per month during COVID-19 (pre-COVID-19: 61 ± 5 vs during COVID-19 19: 39 ± 11; P < .001), and this persisted after excluding the initial 3-month COVID-19 surge (61 ± 5 vs 42 ± 9; P < .001). There were fewer nonelective cases during the initial 3-month COVID-19 surge (32 ± 9 vs 24 ± 4; P = .031), but, excluding the initial surge, there was no difference in nonelective volume (32 ± 9 vs 33 ± 8; P = .560). During COVID-19, patients had lower rates of congestive heart failure (elective: 9.0% vs 6.6%; P = .0047; nonelective: 17.7% vs 11.6%; P < .001) and chronic obstructive pulmonary disease (elective: 13.7% vs 10.2%; P = .017; nonelective: 17.9% vs 12.0%; P < .001) and underwent fewer component separations (10.2% vs 6.4%; P ≤ .001). Intensive care unit admissions decreased for elective ventral hernia repairs (7.7% vs 5.0%; P = .016). Length of stay, cost, and readmission were similar between groups.

CONCLUSION

Elective ventral hernia repair volume decreased during COVID-19 whereas nonelective ventral hernia repairs transiently decreased before returning to baseline. During COVID-19, patients appeared to be lower risk and less complex. The possible impact of the more complex patients delaying surgery is yet to be seen.

Short-term complications after onlay versus preperitoneal mesh repair of umbilical hernias: a prospective randomized double-blind trial

PURPOSE

To compare the incidence of surgical site occurrences (SSOs) following onlay versus preperitoneal mesh placement in elective open umbilical hernia repairs.

METHODS

This study presents a secondary analysis of a randomized double-blind trial conducted on female patients with primary umbilical hernias admitted to a general hospital, in a residency training program setting. Fifty-six subjects were randomly assigned to either onlay (n=30) or preperitoneal (n=26) mesh repair group. Data on baseline demographics, past medical history, perioperative details, postoperative pain (visual analogue scale (VAS)), wound-related complications, and recurrence were assessed using a standardized protocol.

RESULTS

No statistically significant differences were observed between groups regarding patients' demographics, comorbidities, or defect size. Operative time averaged 67.5 (28-110) min for onlay and 50.5 (31-90) min for preperitoneal repairs, p=.03. The overall rate of SSOs was 21.4% (n=12), mainly in the onlay group (33% vs 7.7%; p=0.02, 95% CI 0.03-0.85) and mostly due to seromas. There were no between-group significant differences in postoperative VAS scores at all timepoints. After a maximum follow-up of 48 months, one recurrence was reported in the onlay group. By logistic regression, the onlay technique was the only independent risk factor for SSOs.

CONCLUSION

The presented data identified a decreased wound morbidity in preperitoneal umbilical hernia repairs, thus contributing to the limited body of evidence regarding mesh place selection in future guidelines. Further cases from this ongoing study and completion of follow-up are expected to also compare both techniques in terms of long-term outcomes.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ReBEC) UTN code: U1111-1205-0065 (date of registration: March 27, 2018).

Surgical site infections after emergency hernia repair: substudy from the Management of Acutely Symptomatic Hernia (MASH) study

INTRODUCTION

Acutely symptomatic abdominal wall and groin hernias (ASH) are a common acute surgical presentation. There are limited data to guide decisions related to surgical repair technique and use of antibiotics, which can be driven by increased risk of surgical site infection (SSI) in this group. This study aims to report rates of SSI following ASH repair and explore the use of patient-reported outcome measure reporting in this setting.

METHODS

An 18-week, UK-based, multicentre prospective cohort study (NCT04197271) recruited adults with ASH. This study reports operatively managed patients. Data on patient characteristics, inpatient management, quality of life, complications, and wound healing (Bluebelle score) were collected. Descriptive analyses were performed to estimate event rates of SSI and regression analysis explored the relationship between Bluebelle scores and SSI. The 30 and 90-day follow-up visits assessed complications and quality of life.

RESULTS

The MASH study recruited 273 patients, of whom 218 were eligible for this study, 87.2 per cent who underwent open repair. Mesh was used in 123 patients (50.8 per cent). Pre- and postoperative antibiotics were given in 163 (67.4 per cent) and 28 (11.5 per cent) patients respectively. There were 26 reported SSIs (11.9 per cent). Increased BMI, incisional, femoral, and umbilical hernia were associated with higher rates of SSI (P = 0.006). In 238 patients, there was a difference in healthy utility values at 90 days between patients with and without SSI (P = 0.025). Also, when analysing 191 patients with Bluebelle scores, those who developed an SSI had higher Bluebelle values (P < 0.001).

CONCLUSION

SSI is frequent in repair of acutely symptomatic hernia and correlates with BMI and site of hernia.

Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation

PURPOSE

Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. An important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4 × 4 cm onlay-mesh for umbilical hernias ≤ 2 cm.

METHODS

A retrospective study was conducted at a single centre in Sweden on all umbilical hernia repairs during 2015-2019. The follow-up time was at least four months. Patients were identified using the hospital medical database. Repairs performed with suture or a sublay, ventral patch and laparoscopic mesh positioning were excluded. The patient's demographics, comorbidities, intra-and post-operative details were considered. The primary outcome was surgical site complications within 30 days. The secondary outcome was a recurrence.

RESULTS

80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm. The median (range) follow-up time was 29.0 (4.3-50.1) months. The median age was 46 (26-76) years old. The median body mass index was 28 (19-38) kg/m2. The male to female ratio was 2:1. 4 patients were identified with a surgical site post-operative complication; three with seromas and one with a superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound openings bedside. There were no registered cases of recurrence.

CONCLUSIONS

Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess whether mesh can reduce recurrences in umbilical hernia repairs ≤ 2 cm.

Risk factors for umbilical incisional hernia after laparoscopic colorectal surgery

BACKGROUND

Laparoscopic colorectal surgery (LCRS) requires a small laparotomy at the umbilicus. The wound is small and inconspicuous, but if the patient develops an umbilical incisional hernia (UIH), the wound is visible and the patient suffers from symptoms of discomfort. However, the incidence of UIH after LCRS and its risk factors are not well understood. The purpose of this study was to investigate the risk factors for UIH after LCRS for colorectal cancer.

METHODS

This was a single-centre retrospective study of 135 patients with colorectal cancer, conducted at our hospital from April 2013 to March 2019. The diagnosis of UIH was based on computed tomography and physical examination findings. Preoperative patient data such as enlargement of the umbilical orifice (EUO), subcutaneous fat thickness (SFT) and intraperitoneal thickness (IPT) were collected and analysed using univariate and multivariate analyses for the presence of risk factors for UIH.

RESULTS

A total of 135 patients who underwent LCRS were analysed. The incidence of UIH was 20.7%. Univariate analysis revealed significantly high body mass index (BMI) ≥ 25 (P = 0.032), EUO (P < 0.001), SFT ≥18 mm (P = 0.011), and IPT ≥61 mm (P < 0.01) in the UIH group. Multivariate analysis revealed significant differences in EUO (P < 0.001), SFT ≥18 mm (P = 0.046) and IPT ≥61 mm (P = 0.022).

CONCLUSION

EUO was the most important risk factor for UIH, followed by IPT and SFT. These findings are predictive indicators of the development of UIH after LCRS and can be assessed objectively and easily with preoperative computed tomography.

Hernia recurrence after primary repair of small umbilical hernia defects

BACKGROUND

An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined.

METHODS

A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications.

RESULTS

Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant.

CONCLUSIONS

With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.

Emergency repair and smoking predict recurrence in a large cohort of ventral hernia patients

PURPOSE

Ventral hernias are frequent and hernia repair is regularly performed by general surgeons. Emergency repair is less frequent and can be challenging. Long-term data comparing outcomes of emergency- vs. elective ventral hernia repair are scarce.

METHODS

Consecutive patients undergoing emergency and elective ventral hernia repair at our institution were prospectively entered in our HerniaMed database between August 2013 and February 2020. Patients were contacted after 1 and 5 years to assess long-term complications. Risk factors for emergency repair and hernia recurrence were assessed by univariate and multivariate analysis.

RESULTS

We included 1307 patients. Emergency and elective hernia repair were performed in 11% and 89% of patients with 1-year follow-up rates of 94% and 92%. Female gender, BMI > 40 kg/m², ASA class 3 and 4, large size umbilical herniation (> 4 cm) and epigastric herniation were more frequent in emergency hernia repair. Binary logistic regression analysis identified emergency repair and smoking as predictors of recurrence (Odds ratio: 4.04 and 95% confidence interval: 1.67-14.21, p = 0.004; Odds ratio: 2.94 and 95% confidence interval: 1.33-9.15, p = 0.011). Furthermore, female gender and significant comorbidity (ASA class 3 and 4) were risk factors for emergency repair (Odds ratio: 1.98 and 95% confidence interval: 01.05-3.74, p = 0.034; Odds ratio: 3.54 and 95% confidence interval: 1.79-6.98, p < 0.001).

CONCLUSIONS

Emergency repair and smoking predicted hernia recurrence. Females and highly comorbid patients are at increased risk for emergency repair and should be prioritized for early elective hernia repair.

Variation in approach for small (< 2 cm) ventral hernias across a statewide quality improvement collaborative

INTRODUCTION

Operative technique for hernias < 2 cm is highly controversial. Limited data exist about this practice at a population level. Within this context we sought to describe practice patterns and use of mesh among patients undergoing repair of small hernias within the setting of a statewide quality improvement collaborative.

METHODS

Retrospective cohort study of patients undergoing hernia repair in the Michigan Surgical Quality Collaborative Hernia Registry was conducted. Patients who underwent repair of a hernia < 2 cm from January 1, 2020 to July 8, 2021 were included. Descriptive statistics were performed to describe cohort characteristics and compare patients who did and did not receive mesh. Logistic regression was performed to estimate the odds of receiving mesh after accounting for patient and hernia characteristics.

RESULTS

Among 570 patients, 56.1% (n = 320) had mesh placed. Most repairs were conducted via open approach (n = 437, 76.5%). Patients who received mesh were older (51.8 vs 48.6, p < 0.01), had higher BMI (31.7 vs 30.0, p < 0.01), were more often ASA Class III (35.9% vs 24.4%, p < 0.01), more often had diabetes (15.9% vs 10.0%, 0.04) and hypertension (44.7% vs 30.4%, p < 0.01), and had higher hernia width (1.2 cm vs 1.0 cm, p < 0.0001). After adjustment, ASA Class III (aOR 3.41, 95% CI 1.31-8.89), current smoking status (aOR 1.81, 95% CI 1.04-3.18), higher mean hernia width (aOR 5.68, 95% CI 2.97-10.85), and laparoscopic (aOR 12.9, 95% CI 5.02-32.96) or robotic (aOR 24.3, 95% CI 6.96-84.96) were associated with mesh use, while COPD (aOR 0.36, 95% CI 0.07-0.96) was associated with less mesh use.

CONCLUSIONS

Use of mesh for small hernias remains controversial. We found that patients who had mesh placed at the time of surgery were potentially patients at higher risk for complications. The decision to use mesh may be driven by patient-related factors that predispose to complications and operative recurrence rather than evidence indicating that it is superior in this population.

Umbilical hernia: could it be the 'canary in the coal mine' for a more significant abdominal wall problem?

BACKGROUND

A considerable proportion of incisional hernias presenting to this unit evolve following simple umbilical hernia repair. Our aim was to review our series of complex ventral hernia repairs and identify the frequency of this problem. Our secondary aim was to encourage surgeons to evaluate whether any of the factors that increase the risk of recurrent hernia may be present, prior to undertaking an umbilical hernia repair.

METHODS

Observational retrospective review of a prospectively maintained single-surgeon database of consecutive patients undergoing surgery for recurrent ventral hernia. Patients presenting with recurrence at the site of a previous umbilical hernia repair were identified and their demographic data collected and analysed. A review of the published literature was performed. Patient and surgeon factors contributing to recurrence were identified and discussed.

RESULTS

Of 386 patients undergoing surgery for a recurrent ventral hernial, 102 (26.4%) were initially managed as 'simple' umbilical hernias repaired with a mesh patch or primary suture repair. 71 (69.6%) patients had undergone one or more subsequent hernia repairs prior to referral to our unit with 16 (15.6%) having had three or more repairs prior to referral.

CONCLUSION

Recurrence rates after umbilical hernia repair are likely to be much higher than surgeons and patients appreciate. There are many aspects to consider in the repair of a 'simple' umbilical hernia and we seek promote a discussion amongst surgeons that umbilical hernias be assessed as a major abdominal wall condition and not relegated to minor surgery status.

eTEP inferior access with tailored retromuscular dissection for small to mid-sized umbilical hernia repair with or without inguinal hernia: early experience

INTRODUCTION

The minimally invasive surgical repair of combined inguinal and ventral hernias often requires shifting from one approach or plane to another. The traditional enhanced-view totally extraperitoneal Rives-Stoppa repair consists of a large retro muscular dissection that is unjustified for small ventral hernias. Here we describe a modification to the minimally invasive Rives-Stoppa repair using a limited retro muscular dissection based on the ventral defect size for small/medium-sized hernias, with or without combined inguinal hernias.

METHODS

From a single surgical team, a retrospective study was performed over a 1-year period. Demographics, hernia characteristics, surgical techniques, intraoperative/postoperative complications, and outcomes were all analyzed and reported. We also included detailed surgical steps, landmarks, pitfalls, and personal tips for this technique.

RESULTS

Twenty-four patients underwent a laparoscopic limited retromuscular dissection ventral hernia repair utilizing the eTEP access technique. Eighteen were primary umbilical hernias and six postoperative incisional hernias, and nine were combined ventral and inguinal hernia repairs. Eight of the primary umbilical hernias were EHS classified as medium size, 11 small, and for the incisional hernias, three were classified as M3W1 and two as M3W2. One procedure was converted to TAPP. There were no intraoperative complications. The mean length of stay was 1.25 days (range 1-3). There was one postoperative retromuscular hematoma and no recurrence during the follow-up period.

CONCLUSION

eTEP with limited dissection offers a good and safe solution for small to medium size hernias; it provides an efficient solution when an inguinal hernia is to be addressed as well.

Post-partum abdominal wall insufficiency syndrome (PPAWIS): lessons learned from a single surgeon's experience based on 200 cases

Background

Post-partum abdominal wall insufficiency (PPAWI) with rectus diastasis is present in over 30% of women after pregnancy. Little is known about how PPAWI affects the social, sexual life and self-esteem of patients. This study was designed to evaluate the safety of onlay mesh combined with abdominoplasty and its impact on the well-being of the patients.

Method

Two hundred patients with PPAWI underwent surgery with onlay mesh and abdominoplasty. The safety of the procedure was assessed by postoperative complications, time of hospitalization and time of drainage. Before the operation and 6 months later, a questionnaire asking about the patient’s sexual and social life and the presence of back pain was completed. The final cosmetic effect was assessed separately.

Results

The onlay procedure with abdominoplasty was found to be safe and fast. The mean operation time was 82 min, and the drainage time was 2.1 days. In this group < 2% postoperative complications were noted. There were no recurrences within the 6 month. Significant improvements in social and sexual life and the level of self-esteem were noted. Back pain was relieved or minimalized in all patients. The final cosmetic effect was insufficient for 2 patients (1%).

Conclusion

PPAWI can be treated safely with onlay mesh and abdominoplasty. The patients’ symptoms were strongly correlated with the morphological status of the front abdominal wall and improved after the procedure. Describing the psychological and social consequences of PPAWI should lead the surgical societies to propose a definition of a new disease called PPAWIS (post-partum abdominal wall insufficiency syndrome).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01757-y.

Ventral hernia repair and mesh use in females of childbearing age

BACKGROUND

A substantial knowledge gap exists in understanding sex as a biological variable for abdominal wall hernia repair, which also extends to hernia repair practices in females of childbearing age. We sought to determine the incidence of mesh repairs in females of childbearing age and to characterize factors associated with mesh use.

METHODS

Using a statewide hernia-specific data registry, we conducted a retrospective study identifying females of childbearing age, defined as 18-44 per CDC guidelines, who underwent clean ventral hernia repair between January 2020 and Dec 2021. The primary outcome was mesh use. Multivariable logistic regression was used to examine factors associated with mesh use. To further delineate whether childbearing status may affect decision to use mesh, we also examined mesh practice stratified by age, comparing women 18 to 44 to those 45 and older.

RESULTS

Eight hundred and thirty-six females of childbearing age underwent ventral hernia repair with a mean age of 34.8 (6.2) years. Mesh was used in 547 (65.4%) patients. Mesh use was significantly associated with minimally invasive approach [aOR 29.46 (95% CI 16.30-53.25)], greater hernia width [aOR 1.50 (95% CI 1.20-1.88)], and greater BMI [aOR 1.05 (95% CI 1.03-1.08)]. Age was not significantly associated with mesh use [aOR 1.02 (95% CI 0.99-1.05)]. Compared to 1,461 female patients older than 44 years old, there was no significant association between childbearing age and mesh use [aOR 0.77 (95% CI 0.57-1.04)].

CONCLUSIONS

Most females of childbearing age had mesh placed during ventral and incisional hernia repair, which was largely associated with hernia size, BMI, and a minimally invasive surgical approach. Neither chronologic patient age nor being of childbearing age were associated with mesh use. Insofar as existing evidence suggests that childbearing status is an important factor in deciding whether to use mesh, these findings suggest that real-world practice may not reflect that evidence.

Long-term reoperation rate following primary ventral hernia repair: a register-based study

BACKGROUND

The aim of this study was to analyse the risk for reoperation following primary ventral hernia repair.

METHODS

The study was based on umbilical hernia and epigastric hernia repairs registered in the population-based Swedish National Patient Register (NPR) 2010-2019. Reoperation was defined as repeat repair after primary repair.

RESULTS

Altogether 29,360 umbilical hernia repairs and 6514 epigastric hernia repairs were identified. There were 624 reoperations registered following primary umbilical repair and 137 following primary epigastric repairs. In multivariable Cox proportional hazard analysis, the hazard ratio (HR) for reoperation was 0.292 (95% confidence interval (CI) 0.109-0.782) after open onlay mesh repair, 0.484 (CI 0.366-0.641) after open interstitial mesh repair, 0.382 (CI 0.238-0.613) after open sublay mesh repair, 0.453 (CI 0.169-1.212) after open intraperitoneal onlay mesh repair, 1.004 (CI 0.688-1.464) after laparoscopic repair, and 0.940 (CI 0.502-1.759) after other techniques, when compared to open suture repair as reference method. Following umbilical hernia repair, the risk for reoperation was also significantly higher for patients aged < 50 years (HR 1.669, CI 1.389-2.005), for women (HR 1.401, CI 1.186-1.655), and for patients with liver cirrhosis (HR 2.544, CI 1.049-6.170). For patients undergoing epigastric hernia repair, the only significant risk factor for reoperation was age < 50 years (HR 2.046, CI 1.337-3.130).

CONCLUSIONS

All types of open mesh repair were associated with lower reoperation rates than open suture repair and laparoscopic repair. Female sex, young age and liver cirrhosis were risk factors for reoperation due to hernia recurrence, regardless of method.

The influence of preoperative CT imaging on surgical delay in patients with acutely symptomatic abdominal wall hernias

PURPOSE

Abdominal wall hernias are common in the UK and many present in an emergent fashion. The widespread introduction of computed tomography (CT) imaging has transformed surgical practice but out of hours access can be limited by hospital resources and introduce delays. We investigated the influence of preoperative CT imaging in acutely symptomatic hernia and the association with surgical delay and risks of bowel ischemia.

METHODS

A retrospective analysis of patients undergoing emergency hernia surgery between 2013 and 2021 in a busy UK district general hospital. We evaluated the role of preoperative CT and its influence on timing of surgery, postoperative complications, critical care admission and hospital length of stay.

RESULTS

Five hundred and five patients were studied. Of these, 191 had a preoperative CT scan. Sites of hernia included inguinal in 164 patients (33%); umbilical in 164 (33%); femoral in 69 (14%); incisional in 69 (14%); epigastric in 30 (6%) and Spigelian hernia 9 (2%). Preoperative CT imaging was associated with surgical delay (22.0 h vs 13.0 h, p < 0.001) and an increased need for bowel resection (12% vs 6%, p = 0.027). Delay in surgery was not associated with increased postoperative complications (5% vs 4%, p = 0.474) but was associated with increased critical care admission (11.0% vs 4.8%, p = 0.014).

CONCLUSIONS

Preoperative CT scan for emergent hernias can delay often inevitable surgery and is associated with an increasing need for more complex, resectional surgery .

Randomized controlled trials published on patients with hernias have a high percentage of unreproducible statistics

INTRODUCTION

Surgeons rely on randomized controlled trials (RCT) to compare the effectiveness of treatments. RCTs require careful planning and substantial effort to complete. Because of the careful study design, statistics performed are often easy to reproduce such as Chi-squared or t-test. Issues such as statistical discordance, or reporting statistical results that cannot be reproduced, should be uncommon.

METHODS

RCTs pertaining to hernias were identified in PubMed using the search terms "hernia" and "randomized controlled trial." Studies were selected using a random number generator. Studies were included if the primary outcome could be reproduced using the data and statistical test reported in the manuscript. Discordance between the obtained p-value from our analysis and the published p-value was assessed. Primary outcome was the number of studies that reported p-values that crossed the level of statistical significance (p-value = 0.05) but on reproduction analysis did not.

RESULTS

Of the 100 included RCTs, five reported p-values that crossed the "p = 0.05" threshold that our team was unable to reproduce using the statistical test reported in the manuscript. An additional three studies reported p-values that crossed the "p = 0.05" threshold that our team was unable to reproduce using the appropriate statistical test (i.e., Fisher's exact test when all expected cell counts < 5). All eight studies published p-values < 0.05, whereas, our re-analysis demonstrated p ≥ 0.05.

CONCLUSION

Eight percent of the RCTs analyzed in this study reported p-values < 0.05 that on reproduction analysis was ≥ 0.05. The next steps should be to determine reasons for discordance and how to prevent this from happening.

Are Surgeons of the Abdominal Core Health Quality Collaborative Following Guidelines in Umbilical and Epigastric Hernia Repair?

BACKGROUND

Umbilical and epigastric hernias are among the top three most common hernia surgeries performed in the USA with varied techniques. The European and Americas Hernia Societies (EAHS) recently published guidelines for repair of umbilical and epigastric hernias. We evaluated how closely the general surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and to identify areas for possible improvement.

METHOD

Data from patients undergoing elective and emergent umbilical or epigastric hernia repair from 2013 to 2021 were extracted from the ACHQC database. The procedures performed on eligible subjects were compared to those proposed by the EAHS guidelines. Data was reported as a percentage and a cutoff of 70% was selected to determine compliance.

RESULTS

Based on these criteria, 11,088 patients were included and most of the recommendations, including appropriate preoperative antibiotic dosing (96.1% umbilical; 97.2% epigastric), permanent mesh selection (umbilical 97.8%; 96.1 epigastric), mesh fixation with suture (83.6% umbilical; 75.5% epigastric), use of mesh for open repair of hernias greater than 1 cm (83.6 umbilical; 85.7 epigastric), and primary defect closure during open (98.6% umbilical; 97.5% epigastric) and laparoscopic (99.6% umbilical; 100% epigastric) repair, were met.

DISCUSSION

Surgeons of the ACHQC adhere to most of the published guidelines on umbilical and epigastric hernia repair. Further research is needed to reinforce or modify the existing recommendations. Standardization of surgical approach will facilitate additional research needed to improve procedural efficiency, while reducing negative outcomes and cost.

Losartan modifies mesh integration after abdominal wall repair: an experimental study

PURPOSE

Angiotensin II (AT II) receptor blockers have previously shown to reduce inflammatory response in many settings. We aimed to assess the effects of ATII receptor blocker (Losartan) on mesh integration after abdominal wall repair in a rat model.

METHODS

A total of 16 Wistar-Kyoto (WKY) and 16 previously hypertensive (SHRSP) rats were isolated. An acute ventral hernia followed by a bridged repair with heavyweight polypropylene mesh was performed. Subjects received either normal saline (WKY-C n = 8 and SHRPS-C n = 8) or 40 mg/kg losartan (WKY-L n = 8) and SHRPS-L n = 8) in the postoperative period. Blood pressure was recorded preoperatively and weekly after surgery. Necropsy with en-bloc resection of the abdominal wall was performed at postoperative day 30. Macroscopic and microscopic evaluations of the specimens were conducted. H&E and Masson's trichrome were used for histologic evaluation.

RESULTS

Both groups receiving Losartan showed a significant reduction of blood pressure after surgery (WKY-L: 130/85 vs 116/81 mmHg, SHRPS-L: 176/137 vs 122/101 mmHg, p < 0.01). A significant reduction in mesh incorporation and adherence scores were also observed on macroscopic analysis in Losartan groups (p < 0.01 and p   = 0.02, respectively). Microscopically, higher immature fibroplasia was observed after Losartan, with a significant reduction in scar plate formation and inflammatory response on the prosthetic surface (p = 0.04 and p  = 0.02, respectively).

CONCLUSION

Losartan modifies the interaction between the host tissue and the prosthesis. An impairment in mesh integration and immature fibroplasia in both normotensive and hypertensive rats detected in our model warrants further research.

Management of midline ventral hernias in a surgical department of sub-Saharan Africa: A retrospective cohort study

Introduction

The linea alba is the second most frequent site of abdominal wall hernias after the inguinal region. Prosthetic approach, often recommended, comes up against the low socio-economic level and the availability of these materials in developing countries. Our objective is to evaluate the indications and results of midline ventral hernia surgery.

Methods

This was a retrospective cross-sectional study over 36 months including all adult patients (over 15 years old) treated for primary or recurrent midline ventral hernias. The parameters studied were: age, sex, risk factors, type of hernia according to the classification of the European Hernia Society (EHS), clinical presentation, hernial ring size, surgical technique and results (recurrence, chronic pain).

Results

We included 65 patients. The mean age was 40.5 years ± 16.4. There was a female predominance (56.3%, n = 36) with a sex ratio of 0.77. According to the EHS classification, type M3 (umbilical) was more common (67.2%), followed by type M2 (epigastric) in 25% and M4 (infra-umbilical) in 1.6%. According to the clinical presentation, 85.6% (n = 55) were uncomplicated, 10.9% (n = 7) were strangulated in and 3.1% (n = 2) incarcerated. A primary suture was performed in 93.8% (n = 61) and a mesh repair in 6.15% (n = 4). With a mean follow-up of 8.2 ± 11.9 months, we noted a recurrence in 6.1% (n = 4) and chronic pain in 6.1% (n = 4).

Conclusion

There is a need to individualize or contextualize the guidelines. In our context where meshes are not always available, pure tissue repairs keep their place in the treatment.

•

Umbilical hernias are the most frequent ventral hernia in our study.

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A significant part of the patients consult at the stage of complications.

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Pure tissue repairs are still the most used surgical technique in our context.

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However, there is a non-negligible rate of recurrence (6.1%).

Robotic retromuscular abdominal wall repair using an inverted TEP (iTEP) approach: surgical technique and short-term outcomes

PURPOSE

Robotic retromuscular abdominal wall repair (RAWR) for ventral hernias can be performed transabdominal or extraperitoneal by using an enhanced view totally extraperitoneal repair (eTEP). For defects in the meso- or epigastric region, an inverted approach can be used, starting the development of the totally extraperitoneal plane in the suprapubic region and progressing in a caudal-to-cranial direction (inverted TEP, iTEP). The aim of the study is to present the surgical technique and to report the short-term outcomes.

METHODS

A retrospective analysis of a prospectively maintained database was performed, including patients who underwent a robotic RAWR using the iTEP approach between December 2019 and January 2022. The surgical technique was described, and patients' characteristics and intra- and postoperative parameters were studied and compared to the TARUP technique (robotic transabdominal retromuscular umbilical prosthetic hernia repair).

RESULTS

Thirty-four patients were treated with an iTEP approach, and 14 patients underwent a TARUP procedure. The median length of stay was 1 day (range 1-3), and there were no intraoperative complications in both groups. One patient (3%) required reoperation after an iTEP approach for a small bowel internal herniation due to a rupture of the posterior rectus sheath. There were no recurrences or mortality with a median follow-up of 15 months (range 3-29) in the iTEP group, compared to 35 months (range 29-37) in the TARUP group.

CONCLUSION

For defects in the upper abdominal region, a robotic RAWR with an iTEP approach appears to be safe and feasible. Long-term follow-up is needed to evaluate the late recurrence rate.

Persistent low rates of same-day umbilical hernia repair in Australia over the past 20 years: is there a need to change?

BACKGROUND

Several recent reports have identified significant variations in discharge practices following umbilical hernia repair (UHR). The primary aim of this paper is to determine Australian UHR same day discharge (SDD) rates over the past two decades. Secondary aims are to analyse factors which may contribute to variation in discharge practices, compare Australian UHR SDD rates internationally and determine LOS trends.

METHODS

A retrospective, population-based cohort study was conducted using de-identified data from the Australian Institute of Health and Welfare (1 July 1998 to 30 June 2019). SDD rates and LOS were calculated for age, gender and complexity. Negative binomial models were used to investigate associations between characteristics.

RESULTS

The overall mean UHR SDD rate was 41.2% with a modest improvement over the study period (36.5% to 44.4%, P < 0.0001). The mean LOS was 3.4 days, and this decreased over the study period (P = 0.01). Males had a higher rate of SDD (42.1% vs. 39.4%, P < 0.0001) and shorter LOS (3.0 vs. 3.7 days, P < 0.0001) compared with females. Increased age was associated with decreased SDD (P < 0.0001) and increased LOS (P < 0.0001). Australia's SDD rate was lower than in both New Zealand and the United Kingdom.

CONCLUSION

While SDD and LOS following UHR improved across the study period, SDD rates remain below the RACS recommendation and compare unfavourably internationally. Advancing age and female gender were associated with decreased SDD and increased LOS demonstrating potential areas for improvement. Multiple strategies are discussed to address the persistently low rates of SDD after UHR.

Pathways of the preperitoneal plane: from the “fatty triangle” in Rives to the “fatty trident" in extended retromuscular abdominal wall reconstruction. A tribute to Prof. Schumpelick

PURPOSE

Extended retromuscular dissection performed for abdominal wall reconstruction in complex abdominal wall repair has progressively exposed the anatomy between the peritoneal layer and abdominal wall muscles. This study aimed to assess the morphology and distribution of preperitoneal fat in a cadaveric model and its influence in retromuscular preperitoneal dissections.

METHODS

Thirty frozen cadaver torsos were dissected by posterior component separation. The shape of the preperitoneal fat was identified, and the dimensions and more significant distances were calculated.

RESULTS

The results showed that the preperitoneal fat resembles a trident, exists along the midline under the linea alba, and expands in the epigastric area into a rhomboid shape. The fatty triangle was found to be a part of this rhomboid. Caudally, the midline preperitoneal fat widened under the arcuate line to reach the Retzius space. Laterally, the Bogros space communicated the root of the trident with the paracolic gutters, Toldt's fascia, and pararenal fats, forming the lateral prong of the trident. The peritoneum not covered by the preperitoneal fatty trident was easy to break. Three pathways could be tracked following the distribution of this fat that facilitated the dissection of the preperitoneal space to prepare the landing zone of the meshes in hernia repair.

CONCLUSION

The concept of preperitoneal fatty trident may be of practical assistance to perform various hernia procedures, from the simple ventral hernia repair to the more complex preperitoneal ventral repair or posterior component separation techniques. The consistency of this layer allows us to follow three specific pathways to find our plane between the peritoneum and muscle layers to extend the preperitoneal dissection.

Liquid resorbable nanofibrous surgical mesh: a proof of a concept

BACKGROUND

Surgical mesh is widely used not only to treat but also to prevent incisional hernia formation. Despite much effort by material engineers, the 'ideal' mesh mechanically, biologically and surgically easy to use remains elusive. Advances in tissue engineering and nanomedicine have allowed new concepts to be tested with promising results in both small and large animals. Abandoning the concept of a pre-formed mesh completely for a 'pour in liquid mesh' has never been tested before.

MATERIALS AND METHODS

Thirty rabbits underwent midline laparotomy with closure using an absorbable suture and small stitch small bites technique. In addition, their abdominal wall closure was reinforced by a liquid nanofibrous scaffold composed of a fibrin sealant and nanofibres of poly-ε-caprolactone with or without hyaluronic acid or the sealant alone, poured in as an 'onlay' over the closed abdominal wall. The animals were killed at 6 weeks and their abdominal wall was subjected to histological and biomechanical evaluations.

RESULTS

All the animals survived the study period with no major complication. Histological evaluation showed an eosinophilic infiltration in all groups and foreign body reaction more pronounced in the groups with nanofibres. Biomechanical testing demonstrated that groups treated with nanofibres developed a scar with higher tensile yield strength.

CONCLUSION

The use of nanofibres in a liquid form applied to the closed abdominal wall is easy to use and improves the biomechanical properties of healing fascia at 6 weeks after midline laparotomy in a rabbit model.

Epigastric Hernias in Children: A Personal Series and Systematic Review of the Literature

Epigastric hernias are relatively uncommon in children, and there is a paucity of literature on their incidence, presenting features, natural history, and surgical outcomes. A systematic review was conducted according to PRISMA guidelines. Articles describing the incidence, outcome, and interventions for pediatric epigastric hernias, both open and laparoscopic, were analyzed. Eight relevant articles published between 1975 and 2019 were included in the analysis. Of 81 children, 58% were females, 35% were symptomatic and 8% were multiple. All hernias contained preperitoneal fat only and were repaired using standard open surgery or laparoscopic techniques. No recurrences were recorded. In a personal series of 37 hernias in 36 children of median age 4 years, there were no recurrences; however, this series included two children with a recurrent or persistent epigastric hernia after surgery by others. Epigastric hernias in children are relatively uncommon. They typically contain only preperitoneal fat but more than a third are symptomatic. Standard open repair can be undertaken with minimal morbidity. Laparoscopic repair takes longer and provides a marginal cosmetic benefit.

Abdominal wall hernia is a frequent complication of polycystic liver disease and associated with hepatomegaly

BACKGROUND AND AIM

Polycystic liver disease (PLD) is related to hepatomegaly which causes an increased mechanical pressure on the abdominal wall. This may lead to abdominal wall herniation (AWH). We set out to establish the prevalence of AWH in PLD and explore risk factors.

METHODS

In this cross-sectional cohort study, we assessed the presence of AWHs from PLD patients with at least 1 abdominal computed tomography or magnetic resonance imaging scan. AWH presence on imaging was independently evaluated by two researchers. Data on potential risk factors were extracted from clinical files.

RESULTS

We included 484 patients of which 40.1% (n = 194) had an AWH. We found a clear predominance of umbilical hernias (25.8%, n = 125) while multiple hernias were present in 6.2% (n = 30). Using multivariate analysis, male sex (odds ratio [OR] 2.727 p < .001), abdominal surgery (OR 2.575, p < .001) and disease severity according to the Gigot classification (Type 3 OR 2.853, p < .001) were identified as risk factors. Height-adjusted total liver volume was an independent PLD-specific risk factor in the subgroup of patients with known total liver volume (OR 1.363, p = .001). Patients with multiple hernias were older (62.1 vs. 55.1, p = .001) and more frequently male (22.0% vs. 50.0%, p = .001).

CONCLUSION

AWHs occur frequently in PLD with a predominance of umbilical hernias. Hepatomegaly is a clear disease-specific risk factor.

A propensity-score matched analysis of ventral-TAPP vs. laparoscopic IPOM for small and mid-sized ventral hernias. Comparison of perioperative data, surgical outcome and cost-effectiveness

PURPOSE

Laparoscopic techniques have been used and refined in hernia surgery for several years. The aim of this study was to compare an established method such as laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) with ventral Transabdominal Preperitoneal Patch Plasty (ventral-TAPP) in abdominal wall hernia repair.

METHODS

Patient-related data of 180 laparoscopic ventral hernia repairs between June 2014 and August 2020 were extracted from our prospectively maintained database. Of these patients, 34 underwent ventral-TAPP and 146 lap. IPOM. After excluding hernias with a defect size > 5 cm and obtaining balanced groups with propensity-score matching, a comparative analysis was performed in terms perioperative data, surgical outcomes and cost-effectiveness.

RESULTS

Propensity-score matching suggested 27 patients in each of the two cohorts. The statistical evaluation showed that intake of opiates was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.001). The Visual Analogue Scale (VAS) score after lap. IPOM repair was significantly higher at movement (p = 0.008) and at rest (p = 0.023). Also, maximum subjective pain during hospital stay was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.004). No hernia recurrence was detected in either group. The material costs of ventral-TAPP procedure (34.37 ± 0.47 €) were significantly lower than those of the lap. IPOM group (742.57 ± 128.44 € p = 0.001). The mean operation time was 65.19 ± 26.43 min in the lap. IPOM group and 58.65 ± 18.43 min in the ventral-TAPP cohort. Additionally, the length of hospital stay in the lap. IPOM cohort was significantly longer (p = 0.043).

CONCLUSION

Ventral-TAPP procedures represent an alternative technique to lap. IPOM repair to reduce the risk of complications related to intra-peritoneal position of mesh and fixating devices. In addition, our study showed that postoperative pain level, material costs and hospital stay of the ventral-TAPP cohort are significantly lower compared to lap. IPOM patients.

Guidelines for Treatment of Umbilical and Epigastric Hernias From the European and Americas Hernia Societies-A Web-Based Survey on Surgeons' Opinion

Background and aims: The European and Americas Hernia Society's (EHS and AHS) Guidelines on the treatment of primary midline ventral hernias were launched to guide surgeons. As a part of a dissemination plan of the guideline, this study aimed to evaluate the level of consensus between recommendations and the current surgical practices of EHS and AHS members before implementation. Material and methods: A questionnaire was constructed including questions on the current practice of the members and nine selected key recommendations from the guidelines. An on-stage consensus voting was performed at the EHS Congress in Hamburg 2019 followed by a SurveyMonkey sent to all EHS and AHS members. Consensus with a recommendation was defined as an agreement of ≥70%. Results: A total of 178 votes were collected in Hamburg. A further 499/1,754 (28.4%) of EHS and 150/1,100 (13.6%) of AHS members participated in the SurveyMonkey. A consensus was reached for 7/9 (78%) of the recommendations. The two recommendations that did not reach consensus were on indication and the technique used for laparoscopic repair. In current practice, more AHS participants used a preformed patch; 50.7% (76/150) compared with EHS participants 32.1% (160/499), p < 0.001. Conclusion: A consensus was achieved for most recommendations given by the new guideline for the treatment of umbilical and epigastric hernias. Recommendations that did not reach consensus were on indication and technique for laparoscopic repair, which may reflect the lack of evidence on these topics.

Guideline-discordant care among females undergoing groin hernia repair: the importance of sex as a biologic variable

PURPOSE

Females suffer higher rates of operative recurrence and chronic pain following groin hernia repair. Guidelines recommend minimally invasive (MIS) groin hernia repair as the preferred approach to reduce these adverse outcomes. It is unknown what proportion of females receive MIS hernia repair. Therefore, our goal was to investigate adoption of evidence-based practices in groin hernia repair using sex as a biological variable.

METHODS

Retrospective cohort study of adults undergoing elective groin hernia repair (2014-2019) within a statewide quality improvement collaborative. Primary outcome was surgical approach. Multivariable logistic regression was performed to analyze the likelihood of undergoing MIS hernia repair. Secondary outcomes were 30-day adjusted rates of clinical and patient-reported outcomes (PROs). PROs included regret to undergo surgery among patients who completed post-operative surveys.

RESULTS

Among 23,723 patients, the majority (90.7%) were males. Compared to males, females less often underwent an MIS surgical approach (37.4% vs 45.1%, p < 0.0001). After adjustment for patient and clinical variables, females remained significantly less likely to undergo MIS groin hernia repair (aOR 0.88, 95% CI 0.80-0.97). Adjusted clinical outcomes were not different between males and females. Among 4325 patients who completed post-operative surveys, adjusted rates of regret to undergo surgery were higher among females (12.9% vs 8.5%, p = 0.003).

CONCLUSIONS

Even after adjusting for differences, females were less likely to receive guideline-concordant groin hernia repair and were more likely to regret surgery. Understanding the behaviors of surgeons who treat females with groin hernia may inform quality metrics to promote best practices in this population.

Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality.

Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy.

Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.

Laparoscopic repair for primary epigastric hernia containing falciform ligament: A case report and review of literature

Falciform ligament herniation is a rare type of epigastric hernia. We report a case of a primary epigastric hernia containing a falciform ligament repaired using nonabsorbable barbed suture under laparoscopic surgery. A 74-year-old woman presented with discomfort in the upper abdomen. Physical examination revealed a 3-cm non-tender mass, and abdominal computed tomography revealed epigastric hernia with an incarcerated falciform ligament. By observation with a laparoscope, the fascial defect was single and 1.0 cm in diameter, thus sutured repair was selected. At 4 months follow-up, she had no complications or recurrence. The laparoscopic approach is useful for diagnosis and deciding a repair method of an epigastric hernia. The barbed suture closure system is convenient and effective for intracorporeal hernial defect closing. Both primary and incisional falciform ligament herniation have been reported in the past, and we reviewed six cases, including our case.

Long-term follow-up of full-thickness skin grafting in giant incisional hernia repair: a randomised controlled trial

Purpose

Conventional repair of a giant incisional hernia often requires implantation of a synthetic mesh (SM). However, this surgical procedure can lead to discomfort, pain, and potentially serious complications. Full-thickness skin grafting (FTSG) could offer an alternative to SM, less prone to complications related to implantation of a foreign body in the abdominal wall. The aim of this study was to compare the use of FTSG to conventional SM in the repair of giant incisional hernia.

Methods

Patients with a giant incisional hernia (> 10 cm width) were randomised to repair with either FTSG or SM. 3-month and 1-year follow-ups have already been reported. A clinical follow-up was performed 3 years after repair, assessing potential complications and recurrence. SF-36, EQ-5D and VHPQ questionnaires were answered at 3 years and an average of 9 years (long-term follow-up) after surgery to assess the impact of the intervention on quality-of-life (QoL).

Results

Fifty-two patients were included. Five recurrences in the FTSG group and three in the SM group were noted at the clinical follow-up 3 years after surgery, but the difference was not significant (p = 0.313). No new procedure-related complication had occurred since the one-year follow-up. There were no relevant differences in QoL between the groups. However, there were significant improvemnts in both physical, emotional, and mental domains of the SF-36 questionnaire in both groups.

Conclusion

The results of this long-term follow-up together with the results from previous follow-ups indicate that autologous FTSG as reinforcement in giant incisional hernia repair is an alternative to conventional repair with SM.

Trial Registration

The study was registered August 10, 2011 at ClinicalTrials.gov (ID NCT01413412), retrospectively registered.

Strangled gravidic uterus, an exceptional complication of umbilical hernia during pregnancy, a case report

Introduction

Strangulated pregnancy is a very rare presentation in which the intra umbilical strangulated form is exceptional. To our knowledge, we report the first Moroccan case and one of less than 10 cases published in the literature of a strangulated gravid uterus; in a woman admitted for treatment of umbilical pain.

Case presentation

Through this presentation, we report a sporadic case of hernial strangulation during pregnancy containing an evolving pregnancy in the umbilical harness bag. The suspicion of this diagnosis was clinical and the confirmation made by ultrasound and abdominal MRI for confirmation. The objectives of this publication are threefold: i), to report this new exceptional case ii), to highlight the place of imaging in the management of hernial pathology iii), and to recommend surgical treatment of umbilical hernias in women of childbearing age in order to avoid surgical complications and maternal and fetal morbidity and mortality.

Conclusion

Our case report shows that we should consider this very rare presentation of strangulated pregnancy. Our work also reports another new case to the poor published literature on this subject and emphasizes the importance of surgical management of parietal pathology by focusing on the parietal impact of physiological change during pregnancy.

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Atypical presentation of the strangled uterus.

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A strangled umbilical hernia containing a pregnant uterus being one of less than 10 cases reported in the literature.

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Take into consideration the possibility of complication of parietal pathology during pregnancy.

Robotic hernia repair II. English version : 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.

Feasibility of Umbilical Hernia Repair Under Local Anesthesia and Monitored Anesthesia Care at a Veteran Affairs Hospital

BACKGROUND

Local anesthesia (LA) for open umbilical hernia tissue repair (OUHTR) is not widely utilized in academic centers in the United States. We hypothesize that LA for OUHTR is feasible in a veteran patient population.

METHODS

From 2015 to 2019, 449 umbilical hernias were repaired at our institution utilizing a standardized technique in veteran patients. OUHTR was included in this analysis (n = 283). Since 2017, 18.7% (n = 53) UH were repaired under LA. We compared outcomes and operative times between general anesthesia and LA in patients undergoing OUHTR. Univariable and multivariable analyses were performed to determine significance.

RESULTS

The entire cohort was composed of older (56.3 ± 12.1 years), White (75.5%), obese (body mass index [BMI] = 32.3 ± 4.6 kg/m²) men (98.0%). The average hernia size for the entire cohort was 2.42 ± 1.2 cm. The groups were similar in age and BMI. Patients with higher American Society of Anesthesiologists (ASA) (Odds ratio [OR] 3.1; 95% CI 1.5-6.8) and cardiovascular disease (OR 2.7; 95% CI 1.0-7.2) were more likely to receive LA. Recurrence (0.0% vs 6.0%; P = .9) and 30-day complications (6.0% vs 13%; P = .9) were similar between LA and GA after correcting for hernia size. Operating room times were reduced in the LA group (17.7 minutes; P < .05). None of the patients with LA required postanesthesia care unit for recovery. The patients who received LA reported being comfortable (78.9% of patients), with the worst reported pain being 2.4 ± 2.4 (out of a scale of 10), and 94.7% would elect to receive LA if they had another hernia repair.

CONCLUSION

Patients who received LA had more cardiac disease and a higher ASA. Complications were similar between both groups. LA reduced operating room times. Patients were satisfied with LA.