Multicenter, Prospective, Longitudinal Study of the Recurrence, Surgical Site Infection, and Quality of Life After Contaminated Ventral Hernia Repair Using Biosynthetic Absorbable Mesh: The COBRA Study

Retromuscular Mesh Repair Using Fibrin Glue: Early Outcomes and Cost-effectiveness of an Evolving Technique

Background

Retromuscular hernia repairs (RHRs) decrease hernia recurrence and surgical site infections but can cause significant pain. We aimed to determine if pain and postoperative outcomes differed when comparing suture fixation (SF) of mesh to fibrin glue fixation (FGF).

Methods

Patients undergoing RHR (n = 87) between December 1, 2015 and December 31, 2017 were retrospectively identified. Patients received SF of mesh (n = 59, 67.8%) before the senior author changing his technique to FGF (n = 28, 32.2%). These 2 cohorts were matched (age, body mass index, number of prior repairs, mesh type, defect size, and wound class). Outcomes were analyzed using a matched pairs design with multivariable linear regression.

Results

Two matched groups (21 FGF and 21 SF) were analyzed (45.2% female, average age 56 years, average body mass index 34.7 kg/m², and average defect size 330 cm²). Statistical significance was observed for FGF compared with SF: length of stay (3.7 versus 7.1 days, P = 0.032), time with a drain (17.2 versus 27.5 days, P = 0.012), 30-day postoperative visits (2 versus 3, P = 0.003), pain scores (5.2 versus 3.1, P = 0.019) and activity within the first 24 hours (walking versus sitting, P = 0.002). Operative time decreased by 23.1 minutes (P = 0.352) and postoperative narcotic represcription (3 versus. 8 patients, p=0.147) also decreased. Average cost for patients receiving SF was $36,152 compared to $21,782 for FGF (P = 0.035).

Conclusions

Sutureless RHR using FGF may result in decreased pain when compared with a matched cohort receiving SF, translating to enhanced recovery time, shortened hospital stay, and decreased costs.

Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up

BACKGROUND

The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence.

METHODS

Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas.

RESULTS

Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not.

CONCLUSIONS

With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.

Combined Hartmann's Reversal and Abdominal Wall Reconstruction: Defining Postoperative Morbidity

BACKGROUND

Ventral hernias are common after Hartmann's procedure and add complexity to Hartmann's reversal. Colostomy reversal and abdominal wall reconstruction may be performed in a staged or concurrent fashion, although data are limited as to which strategy is optimal. We aimed to define the complication profile of concurrent abdominal wall reconstruction with colostomy reversal as compared to either procedure alone.

MATERIALS AND METHODS

For this retrospective cohort study, we used the National Surgery Quality Improvement Project Database from 2012 to 2015. All patients undergoing elective colostomy reversal, abdominal wall reconstruction with component separation, or combined colostomy reversal with component separation were identified. Propensity score matching was used to compare outcomes among similar patients undergoing colostomy reversal alone versus combined procedure. Groups were evaluated for postoperative morbidity including reoperation.

RESULTS

We identified 11,689 patients; 6951 (64%) underwent component separation alone, 4563 (35%) colostomy reversal alone, and 175 (1%) combined component separation and colostomy reversal. The combined group, as compared to colostomy reversal alone, showed an increased overall complication rate (39% versus 25%; P < 0.01) and increased rate of reoperation (9% versus 5%; P = 0.03). Differences in overall complication rate (43% versus 24%; P < 0.01) and reoperation rate (9% versus 3%; P = 0.03) persisted on propensity matched analysis.

CONCLUSIONS

This analysis shows that in patients undergoing colostomy takedown, concurrent abdominal wall reconstruction is associated with increased morbidity including increased rate of reoperation, even when controlling for patient factors. Consideration may be given to a staged approach.

Diaphragmatic Hernia Repair Using Biosynthetic Tissue Reinforcement Patch: A Case Series Experience

Diaphragmatic hernias are commonly encountered by general surgeons. However, repair is often fraught with complications and recurrence. The use of extracellular matrix scaffolds for repair of damaged tissues through constructive remodeling is an effective surgical adjunct. Herein, we describe the repair of diaphragmatic hernias using GORE® BIO-A® Tissue Reinforcement patch in a series of patients.

Biodegradable hyaluronan hydrogel coatings on acellular dermis grafts-A potential strategy to improve biologic graft durability in hernia repair application

Biologic grafts used in hernia repair undergo rapid cellular infiltration and remodeling, but their premature degradation often results in hernia recurrence. We hypothesize that a temporary barrier that prevents infiltration of acute inflammatory cells into the graft during the initial 4 weeks of implantation could mitigate graft degradation. The purpose of this study is to design tyramine-substituted hyaluronan (THA) hydrogel coatings with tunable degradation properties, as a means to develop a resorbable barrier for human acellular dermis grafts (HADM). THA plugs prepared at different cross-linking densities, by varying cross-linking agent concentration (0.0001-0.0075% H₂ O₂ ), demonstrated varying rates of in vitro degradation (25 U/mL hyaluronidase, 48 h). Based on these results, HADM grafts were coated with THA at three cross-linking densities (0.0001%, 0.00075%, and 0.003% H₂ O₂ ) and THA coating degradation was evaluated in vitro (25 U/mL hyaluronidase, 48 h) and in vivo (rat intraperitoneal implantation, 1-4 weeks). THA coatings degraded in vitro and in vivo with the lowest cross-linking density (0.0001% H₂ O₂ ), generally showing greater degradation as evidenced by significant decrease in coating cross-sectional area. However, all three coatings remained partially degraded after 4 weeks of in vivo implantation. Alternate strategies to accelerate in vivo degradation of THA coatings are required to allow investigation of the study hypothesis. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B:2664-2672, 2019.

A Current Review of Long-Acting Resorbable Meshes in Abdominal Wall Reconstruction

Concern for chronic infection of a permanent synthetic material in contaminated and "high risk" ventral hernia repairs has led to the development and dissemination of slowly resorbable biosynthetic materials at a lower cost compared with biologic mesh counterparts. Here, we review the preclinical and clinical data available for each long-acting resorbable mesh, with a candid comparison to biologic and synthetic equivalents.

Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience

BACKGROUND

Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem.

METHODS

Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients.

RESULTS

A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: "conservative management," "excision of mesh with primary closure," "single-stage reconstruction," "immediate staged repair," and "repair in contaminated field." Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional ("secondary") repairs after recurrence, 75% were eventually able to achieve "hernia-free" state.

CONCLUSIONS

This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.

Retro-rectus placement of bio-absorbable mesh improves patient outcomes

BACKGROUND

There is little consensus on the ideal anatomical placement of bio-absorbable mesh. We hypothesized that retro-rectus placement of bio-absorbable mesh would significantly reduce recurrence rates when compared to intraperitoneal mesh placement.

METHODS

A retrospective review was conducted of patients who underwent open complex ventral hernia repair using bio-absorbable mesh (Bio-A, Gore, Flagstaff, AZ). Patient demographics and Centers for Disease Control wound type were collected.

RESULTS

A total of 81 patients were included. Seventy-four (91.4%) of these hernia repairs had mesh in the retro-rectus position, while 7 (8.6%) had intraperitoneal mesh placement. Patient demographics, including preoperative comorbidities, did not differ between groups. The retro-rectus group trended to have larger hernia defects (156.2 cm²) compared to the intraperitoneal group (63.9 cm²) (p = 0.058). Overall complications (e.g., dehiscence, wound drainage, cellulitis, sepsis) were also similar in both groups of patients. Recurrence rates in the retro-rectus and intraperitoneal group were 8.1% and 42.9%, respectively (p = 0.005). When evaluating only patients with CDC class 1 wounds, the recurrence rate in the retro-rectus group was 8.2% and the intraperitoneal group was 50% (p = 0.02). Overall, the average patient follow-up was 22 months and did not differ between groups. Both the retro-rectus and intraperitoneal groups indicated a significant (p < 0.05) improvement in quality of life from baseline. No long-term (> 7 days) antibiotics were used and no mesh implants were removed during the study.

CONCLUSION

Patients who underwent open complex ventral hernia repairs with bio-absorbable mesh in the retro-rectus position experienced lower overall complication rates than those with intraperitoneal mesh placement. Despite a larger hernia defect in the retro-rectus group, recurrence rates were significantly reduced with retro-rectus placement of mesh compared to intraperitoneal placement. In addition, recurrence rates using bio-absorbable mesh in clean wounds are comparable to previously published recurrence rates with permanent mesh.

A Current Review of Hybrid Meshes in Abdominal Wall Reconstruction

Complex abdominal wall defects remain a common problem, though there has been significant advancement in technique and biomaterials over the last decade. The newly developed hybrid meshes are targeted to address several shortcomings of other meshes. Specifically, the marriage of biosynthetic or biologic materials with permanent prosthetic material is designed so that each will counteract the other's negative attributes. There are reports of permanent meshes having been associated with chronic pain, stiffness, and inflammation. However, their utility in maintaining biomechanical strength, thus limiting recurrence, makes them of value. In hybrid meshes, biosynthetic or biologic materials are coupled with permanent prosthetics, potentially protecting them from exhibiting deleterious effects by promoting and hastening tissue ingrowth. The various hybrid meshes currently available and investigational data are reviewed.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Patients Undergoing Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative: A Prospective Cohort Study

BACKGROUND

Parastomal hernia is the most common complication after stoma creation. It can create significant morbidity and is associated with a lower quality of life. Current parastomal hernia repair techniques and outcomes are not well characterized. We aimed to describe patient characteristics, operative techniques, and outcomes of patients undergoing parastomal hernia repair.

STUDY DESIGN

Patients in the Americas Hernia Society Quality Collaborative (AHSQC) ≥18 years old, who underwent parastomal hernia repair were identified. Descriptive statistics were performed for patient demographics, preoperative characteristics, operative details, 30-day follow-up, and patient-reported outcomes. The surgical techniques used in parastomal hernia repair and postoperative outcomes were described, and predictors of open vs minimally invasive surgery (MIS) and type of mesh used were analyzed.

RESULTS

We identified 672 patients in the AHSQC who underwent parastomal hernia repair between 2013 and Nov 2017. Almost all operations were elective, 22% of patents had their stoma reversed, and 94% of repairs used mesh. Elective status and surgeon practice type were associated with use of synthetic mesh. A surgeon's preference for MIS, defect size, and age were associated with use of an MIS approach. Quality of life scores improved for patients who completed a postoperative questionnaire.

CONCLUSIONS

This is the first multi-institutional report of parastomal hernia repair using prospective data complete with operative details. Parastomal hernia repair remains a difficult operation without a clear best practice. Multiple factors appear to influence operative approach. Surgical treatment may improve quality of life at 6 to 12 months postoperatively.

Retromuscular Sublay Technique for Ventral Hernia Repair

Rives and Stoppa described the sublay technique of hernia repair more than half a century ago, but it took almost three decades to become truly appreciated and even longer for its full clinical potential and benefits to be realized. Modifications to the original operation have significantly improved surgical approaches, postsurgical outcomes, and quality of life. The retromuscular approach requires technical expertise and a firm grasp of the anatomy. With constant substitution of the terms sublay, retrorectus, retromuscular, preperitoneal, and Rives-Stoppa throughout the literature, the nuances need to be distinguished to appreciate the surgical planes encountered during the operation. This article explains the origin of the nomenclature while clarifying these terms, describing the technique, highlighting outcomes, and discussing future considerations.

Systematic review of the stage of innovation of biological mesh for complex or contaminated abdominal wall closure

Background

Achieving stable closure of complex or contaminated abdominal wall incisions remains challenging. This study aimed to characterize the stage of innovation for biological mesh devices used during complex abdominal wall reconstruction and to evaluate the quality of current evidence.

Methods

A systematic review was performed of published and ongoing studies between January 2000 and September 2017. Eligible studies were those where a biological mesh was used to support fascial closure, either prophylactically after midline laparotomy, or for reinforcement after repair of incisional hernia with midline incision. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measure was the GRADE criteria for study quality.

Results

Thirty‐five studies including 2681 patients were included. Four studies considered mesh prophylaxis, 23 considered hernia repair, and eight reported on both. There was one published randomized trial (IDEAL stage 3), none of which was of high quality; the others were non‐randomized studies (IDEAL stage 2a). A detailed description of surgical technique was provided in most studies (27 of 35); however, no study reported outcomes according to the European Hernia Society consensus statement and only two described quality control of surgical technique during the study. From 21 ongoing randomized trials and observational studies, 11 considered repair of incisional hernia and 10 considered prophylaxis (seven in elective settings).

Conclusion

The evidence base for biological mesh is limited, and better reporting and quality control of surgical techniques are needed. Although results of ongoing trials over the next decade will improve the evidence base, further study is required in the emergency and contaminated settings.

Retrorectus repair of incisional ventral hernia with urinary bladder matrix reinforcement in a long-term porcine model

Aim: Not all biologically derived materials elicit the same host response when used for reinforcement of ventral hernia repairs. This study aimed to evaluate the remodeling characteristics of the abdominal wall following reinforcement with urinary bladder matrix (UBM) in a large animal preclinical model of ventral hernia repair. Materials & methods: Midline defects in 36 Yucatan minipigs were reinforced with UBM-derived surgical devices using a classic Rives–Stoppa–Wantz approach, and compared with primary repair controls. After 3 or 8 months, the abdominal wall was explanted for histological and mechanical analysis. Results & conclusion: All UBM-derived surgical devices were completely resorbed within 8 months and facilitated deposition of vascularized, biomechanically functional connective tissue in the retrorectus plane, with no evidence of hernia formation.

Impact of inadvertent enterotomy on short-term outcomes after ventral hernia repair: An AHSQC analysis

BACKGROUND

Patients undergoing ventral hernia repair (VHR) are at risk of an inadvertent enterotomy during surgery. Inadvertent enterotomies potentially contaminate the surgical field presenting a management dilemma for the surgeon. The aim of our study was to define the incidence and risk factors for a recognized inadvertent enterotomy and determine its impact on short-term outcomes after ventral hernia repair.

METHODS

Using a nationwide hernia registry, the Americas Hernia Society Quality Collaborative, we reviewed all ventral hernia repair performed between 2013 and 2017. Patients were assessed for full-thickness inadvertent enterotomies at the time of surgery. Patients with inadvertent enterotomies and without enterotomies were compared to assess differences in 30-day outcomes, using regression modeling.

RESULTS

A total of 5,916 patients were included. The incidence of inadvertent enterotomy was 1.9%, with no difference between open and laparoscopic approaches. Inadvertent enterotomies did not increase surgical site occurrences but there were more surgical site infections (OR: 2.20 [95% CI: 1.24-3.90], P = .007). Patients were less likely to receive mesh if there was an enterotomy. Inadvertent enterotomies led to higher rates of reoperations, readmission, enterocutaneous fistulas, and mortality.

CONCLUSION

Inadvertent enterotomies are more common in complex cases of ventral hernia repair and have an overall incidence of 1.9%. These patients are at increased risk of surgical site infections, reoperations, readmission, and mortality. Although definitive hernia repair with mesh can be safely performed, surgeons should consider multiple factors, including type of mesh and location of mesh in the abdominal wall, before proceeding with definitive repair in any case of an enterotomy.

Updates in Mesh and Biomaterials

Prior publications of the Surgical Clinics of North America have highlighted the technical challenges of abdominal wall reconstruction. This article provides an update on synthetic, biologic, and biosynthetic mesh research since the 2013 Surgical Clinics of North America hernia publication and highlights the future of mesh research. This update features research that has been conducted since the prior publication to guide surgeons to choose the best and most appropriate mesh for their patients.

Prophylactic mesh augmentation: Patient selection, techniques, and early outcomes

BACKGROUND

Incisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient selection, techniques and early outcomes after PMA.

METHODS

Retrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017.

RESULTS

18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m²). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups.

CONCLUSIONS

Early results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION

Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.

METHODS

A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.

RESULTS

The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.

CONCLUSION

The routine use of biologic and biosynthetic meshes cannot be recommended.

Incisional Hernia in the United States: Trends in Hospital Encounters and Corresponding Healthcare Charges

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.

Impact of incisional hernia development following abdominal operations on total healthcare cost

BACKGROUND

Introduction of the category III CPT code (0437T) for prophylactic mesh augmentation (PMA) highlights efforts to reduce incisional hernia (IH). PMA's value in the context of value-based care requires understanding both the cost of IH development and the savings from prevention. We hypothesized large healthcare costs with IH development. Appreciating which subsets of patients are at highest risk for IH, and the subsets who have the costliest care is essential in targeting interventions for hernia prevention.

METHODS

Retrospective cohort study utilizing data from Truven Health Analytic MarketScan Commercial Claims and Encounters Database from calendar years 2011-2014. Adults undergoing open abdominal operations with continued enrollment 3-year post-surgery were included. Inpatient and outpatient claims were tracked over 3 years to identify IH. Quantile regression estimated the association between conditional distribution of total cost and IH. A generalized linear model with gamma distribution estimated the association of conditional mean of total cost and IH. Models were adjusted for confounding cost covariates (e.g., age, gender, obesity, smoking, cancer).

RESULTS

14,290 patients were identified, 1294 (9.1%) developed IH, 48% within 1-year, 33% at 1-2 years, and 19% at 2-3 years post-surgery. 515 underwent stoma creation, 4579 colon resection, 2263 liver/kidney, 3890 peritoneal, 3043 other (foregut, appendectomy, cholecystectomy). Rate of IH formation was 25, 13, 5.9, 6.3, and 6.3%, respectively. The difference in median expenditures for IH development versus no IH was ostomies: $26,098, colorectal: $21,211, liver/kidney: $23,811, peritoneal: $25,554, others: $28,870 (p < 0.0.01). IH within 1 year was more expensive than within 3 years in the following categories: colorectal ($16,034, p = 0.0385), liver/kidney ($27,145, p = 0.0004), and ostomy ($18,992, p = 0.0035).

CONCLUSION

IH is a common occurrence imposing significant healthcare burden. Higher costs occur when IH occurs within 1 year versus 3 years from the index-procedure. This highlights the importance of hernia prevention techniques and the question of whether temporizing closure adjuncts  are appropriate in high-risk patients.

Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias

BACKGROUND

Reversal of an enterostomy results in a high rate of incisional hernia at the ostomy site. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. We present the outcomes of a series of prophylactic mesh reinforcements with retromuscular, large-pore polypropylene at the time of enterostomy reversal.

METHODS

Retrospective review of all ostomy reversals was performed. All cases with placement of synthetic mesh reinforcement were identified from a prospectively maintained, hernia database. Primary end points were surgical site occurrence, surgical site infection, and hernia occurrence.

RESULTS

Ostomy reversal was performed in 359 patients; 91 were reinforced with mesh and 268 without mesh. Colostomy reversal was performed in 56.5% and ileostomy in 43.5%. The mesh group had a greater body mass index and a greater incidence of chronic obstructive pulmonary disease, but groups were otherwise similar. A midline incisional hernia was present in 45% of the mesh group vs 4.5% in the controls. Incidence of surgical site occurrence and surgical site infection were similar for mesh and control groups (21 vs 22.8%; P = .82 and 20 vs 19.8%; P = 1.000, respectively). Superficial surgical site infection was less with mesh (8 vs 16.4%; P = .039). Incidence of a hernia developing at the stoma site was decreased markedly with mesh (1% vs 17.2%; P < .001), as was the occurrence of a midline hernia (6% vs 19%; P = .004). Mesh was placed across the midline prophylactically in 29.7% of cases, which decreased midline hernia formation from 24.1% to 4% (P = .019).

CONCLUSION

Retromuscular placement of permanent synthetic mesh at the time of enterostomy reversal is effective in preventing development of incisional hernia without increased risk of surgical site occurrence or surgical site infection.

Patterns of Recurrence and Mechanisms of Failure after Open Ventral Hernia Repair with Mesh

Recurrence after ventral hernia repair (VHR) remains a significant complication. We sought to identify the technical aspects of VHR associated with recurrence. Patients who underwent open midline VHR between 2006 and 2013 (n = 261) were retrospectively evaluated. Patients with recurrence (Group 1, n = 48) were compared with those without recurrence (Group 2, n = 213). Smoking, diabetes, and body mass index were not different between groups. More patients in Group 1 underwent clean-contaminated, contaminated, or dirty procedures (43.8 vs 27.7%; P = 0.021). Group 1 had a higher incidence of surgical site occurrence (52.1 vs 32.9%; P = 0.020) and surgical site infection (43.8 vs 15.5%; P < 0.001). Recurrences were due to central mesh failure (CMF) (39.6%), midline recurrence after biologic or bioabsorbable mesh repair (18.8%), superior midline (16.7%), lateral (16.7%), and after mesh explantation (12.5%). Most CMF (78.9%) occurred with light-weight polypropylene (LWPP). Recurrence was higher if the midline fascia was unable to be closed. Recurrence with midweight polypropylene (MWPP) was lower than biologic (P < 0.001), bioabsorbable (P = 0.006), and light-weight polypropylene (P = 0.046) mesh. Fixation, component separation technique, and mesh position were not different between groups. Wound complications are associated with subsequent recurrence, whereas midweight polypropylene is associated with a lower overall risk of recurrence and, specifically, CMF.

Mesh sutured repairs of contaminated incisional hernias

BACKGROUND

We sought to evaluate the results of a new mesh sutured repair technique for closure of contaminated incisional hernias.

METHODS

48 patients with contaminated hernias 5 cm wide or greater by CT scan were closed with mesh sutures. Surgical site occurrence, infections, and hernia recurrence were compared to similar patient series reported in the literature.

RESULTS

Of the 48 patients, 20 had clean-contaminated wounds, 16 had contaminated wounds, and 12 were infected. 69% of the patients underwent an anterior perforator sparing components release for hernias that averaged 10.5 cm transversely (range 5 cm-25 cm). SSO occurred in 27% of patients while SSI was 19%. There were no fistulas or delayed suture sinuses. With a mean follow-up of almost 12 months, 3 midline hernias recurred (6%). In these same patients, three parastomal hernias repaired with mesh sutures failed out of 4 attempted for a total failure rate of 13%.

CONCLUSION

Mesh sutured closure represents a simplified and effective surgical strategy for contaminated midline incisional hernia repair.

Early Wound Morbidity after Open Ventral Hernia Repair with Biosynthetic or Polypropylene Mesh

BACKGROUND

Recently introduced slow-resorbing biosynthetic and non-resorbing macroporous polypropylene meshes are being used in hernias with clean-contaminated and contaminated wounds. However, information about the use of biosynthetic meshes and their outcomes compared with polypropylene meshes in clean-contaminated and contaminated cases is lacking. Here we evaluate the use of biosynthetic mesh and polypropylene mesh in elective open ventral hernia repair (OVHR) and investigate differences in early wound morbidity after OVHR within clean-contaminated and contaminated cases.

STUDY DESIGN

All elective, OVHR with biosynthetic mesh or uncoated polypropylene mesh from January 2013 through October 2016 were identified within the Americas Hernia Society Quality Collaborative. Association of mesh type with 30-day wound events in clean-contaminated or contaminated wounds was investigated using a 1:3 propensity-matched analysis.

RESULTS

Biosynthetic meshes were used in 8.5% (175 of 2,051) of elective OVHR, with the majority (57.1%) used in low-risk or comorbid clean cases. Propensity-matched analysis in clean-contaminated and contaminated cases showed no significant difference between biosynthetic mesh and polypropylene mesh groups for 30-day surgical site occurrences (20.7% vs 16.7%; p = 0.49) or unplanned readmission (13.8% vs 9.8%; p = 0.4). However, surgical site infections (22.4% vs 10.9%; p = 0.03), surgical site occurrences requiring procedural intervention (24.1% vs 13.2%; p = 0.049), and reoperation rates (13.8% vs 4.0%; p = 0.009) were significantly higher in the biosynthetic group.

CONCLUSIONS

Biosynthetic mesh appears to have higher rates of 30-day wound morbidity compared with polypropylene mesh in elective OVHR with clean-contaminated or contaminated wounds. Additional post-market analysis is needed to provide evidence defining best mesh choices, location, and surgical technique for repairing contaminated ventral hernias.

Outcomes following repair of incarcerated and strangulated ventral hernias with or without synthetic mesh

Background

The use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence.

Methods

The records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence.

Results

One hundred twenty-two patients (56 males) of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI.

Conclusion

Following established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair.

Trial registration

Research Registry, researchregistry1891

Evaluation of a fully absorbable poly-4-hydroxybutyrate/absorbable barrier composite mesh in a porcine model of ventral hernia repair

Background

The objective of this study was to evaluate the mechanical and histological properties of a fully absorbable poly-4-hydroxybutyrate/absorbable barrier composite mesh (Phasix™ ST) compared to partially absorbable (Ventralight™ ST), fully absorbable (Phasix™), and biologically derived (Strattice™) meshes in a porcine model of ventral hernia repair.

Methods

Bilateral abdominal surgical defects were created in twenty-four Yucatan pigs, repaired with intraperitoneal (Phasix™ ST, Ventralight™ ST) or retromuscular (Phasix™, Strattice™) mesh, and evaluated at 12 and 24 weeks (n = 6 mesh/group/time point).

Results

Prior to implantation, Strattice™ demonstrated significantly higher (p < 0.001) strength (636.6 ± 192.1 N) compared to Ventralight™ ST (324.3 ± 37.1 N), Phasix™ ST (206.9 ± 11.3 N), and Phasix™ (200.6 ± 25.2 N). At 12 and 24 weeks, mesh/repair strength was significantly greater than NAW (p < 0.01 in all cases), and no significant changes in strength were observed for any meshes between 12 and 24 weeks (p > 0.05). Phasix™ mesh/repair strength was significantly greater than Strattice™ (p < 0.001) at 12 and 24 weeks, and Ventralight™ ST mesh/repair strength was significantly greater than Phasix™ ST mesh (p < 0.05) at 24 weeks. At 12 and 24 weeks, Phasix™ ST and Ventralight™ ST were associated with mild inflammation and minimal–mild fibrosis/neovascularization, with no significant differences between groups. At both time points, Phasix™ was associated with minimal–mild inflammation/fibrosis and mild neovascularization. Strattice™ was associated with minimal inflammation/fibrosis, with minimal neovascularization at 12 weeks, which increased to mild by 24 weeks. Strattice™ exhibited significantly less neovascularization than Phasix™ at 12 weeks and significantly greater inflammation at 24 weeks due to remodeling.

Conclusions

Phasix™ ST demonstrated mechanical and histological properties comparable to partially absorbable (Ventralight™ ST) and fully resorbable (Phasix™) meshes at 12 and 24 weeks in this model. Data also suggest that fully absorbable meshes with longer-term resorption profiles may provide improved mechanical and histological properties compared to biologically derived scaffolds.