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Messer N, Ellis RC, Maskal SM, Chang JH, Prabhu AS, Miller BT, Beffa LR, Petro CC, Mazzola Poli de Figueiredo S, Fafaj A, Essani V, Rosen MJ. Sequential surgeries following transversus abdominis release for abdominal wall reconstruction: Insights from a single-center analysis. Am J Surg 2024; 234:99-104. [PMID: 38580567 DOI: 10.1016/j.amjsurg.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Abdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. Despite the popularity of the TAR procedure, current literature regarding post-AWR surgeries is limited. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind. METHODS Adult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence. RESULTS A total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% of the patients required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17-30 months, resulting in a 36.1% recurrent hernia diagnosis rate. CONCLUSIONS Abdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases.
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Affiliation(s)
- Nir Messer
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA; Department of Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel -Aviv University, Tel Aviv, Israel.
| | - Ryan C Ellis
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sara M Maskal
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jenny H Chang
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin T Miller
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lucas Ra Beffa
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Aldo Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Varisha Essani
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Wilson HH, Ma C, Ku D, Scarola GT, Augenstein VA, Colavita PD, Heniford BT. Deep learning model utilizing clinical data alone outperforms image-based model for hernia recurrence following abdominal wall reconstruction with long-term follow up. Surg Endosc 2024; 38:3984-3991. [PMID: 38862826 PMCID: PMC11219459 DOI: 10.1007/s00464-024-10980-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/02/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Deep learning models (DLMs) using preoperative computed tomography (CT) imaging have shown promise in predicting outcomes following abdominal wall reconstruction (AWR), including component separation, wound complications, and pulmonary failure. This study aimed to apply these methods in predicting hernia recurrence and to evaluate if incorporating additional clinical data would improve the DLM's predictive ability. METHODS Patients were identified from a prospectively maintained single-institution database. Those who underwent AWR with available preoperative CTs were included, and those with < 18 months of follow up were excluded. Patients were separated into a training (80%) set and a testing (20%) set. A DLM was trained on the images only, and another DLM was trained on demographics only: age, sex, BMI, diabetes, and history of tobacco use. A mixed-value DLM incorporated data from both. The DLMs were evaluated by the area under the curve (AUC) in predicting recurrence. RESULTS The models evaluated data from 190 AWR patients with a 14.7% recurrence rate after an average follow up of more than 7 years (mean ± SD: 86 ± 39 months; median [Q1, Q3]: 85.4 [56.1, 113.1]). Patients had a mean age of 57.5 ± 12.3 years and were majority (65.8%) female with a BMI of 34.2 ± 7.9 kg/m2. There were 28.9% with diabetes and 16.8% with a history of tobacco use. The AUCs for the imaging DLM, clinical DLM, and combined DLM were 0.500, 0.667, and 0.604, respectively. CONCLUSIONS The clinical-only DLM outperformed both the image-only DLM and the mixed-value DLM in predicting recurrence. While all three models were poorly predictive of recurrence, the clinical-only DLM was the most predictive. These findings may indicate that imaging characteristics are not as useful for predicting recurrence as they have been for other AWR outcomes. Further research should focus on understanding the imaging characteristics that are identified by these DLMs and expanding the demographic information incorporated in the clinical-only DLM to further enhance the predictive ability of this model.
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Affiliation(s)
- Hadley H Wilson
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Chiyu Ma
- Department of Statistical Science, Duke University, Durham, NC, USA
| | - Dau Ku
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
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Ellis RC, Maskal SM, Messer N, Miller BT, Petro CC, Prabhu AS, Rosen MJ, Zheng X, Beffa LRA. Short-term outcomes of heavyweight versus mediumweight synthetic mesh in a retrospective cohort of clean-contaminated and contaminated retromuscular ventral hernia repairs. Surg Endosc 2024; 38:4006-4013. [PMID: 38862822 PMCID: PMC11219365 DOI: 10.1007/s00464-024-10946-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/19/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Mediumweight (40-60 g/m2) polypropylene (MWPP) mesh has been shown to be safe and effective in CDC class II-III retromuscular ventral hernia repairs (RMVHR). However, MWPP has the potential to fracture, and it is possible that heavyweight (> 75 g/m2) polypropylene mesh has similar outcomes in this context. However, there is limited data on HWPP mesh performance in clean-contaminated and contaminated scenarios. We aimed to compare HWPP to MWPP mesh in CDC class II-III wounds during open RMVHR. METHODS The Abdominal Core Health Quality Collaborative database was retrospectively queried for a cohort of patients who underwent open RMVHR with MWPP or HWPP mesh placed in CDC class II/III wounds from 2012 to 2023. Mesh types were compared using a 3:1 propensity score-matched analysis. Covariates for matching included CDC classification, BMI, diabetes, smoking within 1 year, hernia, and mesh width. Primary outcome of interest included wound complications. Secondary outcomes included reoperations and readmissions at 30 days. RESULTS A total of 1496 patients received MWPP or HWPP (1378 vs. 118, respectively) in contaminated RMVHR. After propensity score matching, 351 patients remained in the mediumweight and 117 in the heavyweight mesh group. There were no significant differences in surgical site infection (SSI) rates (13.4% vs. 14.5%, p = 0.877), including deep SSIs (0.3% vs. 0%, p = 1), surgical site occurrence rates (17.9% vs. 22.2%, p = 0.377), surgical site occurrence requiring procedural intervention (16% vs. 17.9%, p = 0.719), mesh removal (0.3% vs. 0%, p = 1), reoperations (4.6% vs. 2.6%, p = 0.428), or readmissions (12.3% vs. 9.4%, p = 0.504) at 30 days. CONCLUSION HWPP mesh was not associated with increased wound morbidity, mesh excisions, reoperations, or readmissions in the early postoperative period compared with MWPP mesh in open RMVHR for CDC II/III cases. Longer follow-up will be necessary to determine if HWPP mesh may be a suitable alternative to MWPP mesh in contaminated scenarios.
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Affiliation(s)
- Ryan C Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Sara M Maskal
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Nir Messer
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Benjamin T Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Clayton C Petro
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ajita S Prabhu
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Michael J Rosen
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell College of Medicine, New York, NY, USA
| | - Lucas R A Beffa
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Mario G, Gennaro P, Elena B, Luciano PG, Fausto C. Comment to: Biosynthetic meshes in contaminated fields: where are we now? A systematic review and meta-analysis in humans. Hernia 2024:10.1007/s10029-024-03096-8. [PMID: 38900354 DOI: 10.1007/s10029-024-03096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Giuffrida Mario
- Department of General Surgery, Ospedale Guglielmo da Saliceto, Piacenza, 29100, Italy.
| | - Perrone Gennaro
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Bonati Elena
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Parma, Italy
| | | | - Catena Fausto
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
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Capella-Monsonís H, Crum RJ, Hussey GS, Badylak SF. Advances, challenges, and future directions in the clinical translation of ECM biomaterials for regenerative medicine applications. Adv Drug Deliv Rev 2024; 211:115347. [PMID: 38844005 DOI: 10.1016/j.addr.2024.115347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/11/2024]
Abstract
Extracellular Matrix (ECM) scaffolds and biomaterials have been widely used for decades across a variety of diverse clinical applications and have been implanted in millions of patients worldwide. ECM-based biomaterials have been especially successful in soft tissue repair applications but their utility in other clinical applications such as for regeneration of bone or neural tissue is less well understood. The beneficial healing outcome with the use of ECM biomaterials is the result of their biocompatibility, their biophysical properties and their ability to modify cell behavior after injury. As a consequence of successful clinical outcomes, there has been motivation for the development of next-generation formulations of ECM materials ranging from hydrogels, bioinks, powders, to whole organ or tissue scaffolds. The continued development of novel ECM formulations as well as active research interest in these materials ensures a wealth of possibilities for future clinical translation and innovation in regenerative medicine. The clinical translation of next generation formulations ECM scaffolds faces predictable challenges such as manufacturing, manageable regulatory pathways, surgical implantation, and the cost required to address these challenges. The current status of ECM-based biomaterials, including clinical translation, novel formulations and therapies currently under development, and the challenges that limit clinical translation of ECM biomaterials are reviewed herein.
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Affiliation(s)
- Héctor Capella-Monsonís
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, USA; Department of Surgery, School of Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA; Viscus Biologics LLC, 2603 Miles Road, Cleveland, OH 44128, USA
| | - Raphael J Crum
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, USA; Department of Surgery, School of Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - George S Hussey
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, USA; Department of Pathology, School of Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Stephen F Badylak
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, USA; Department of Surgery, School of Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA; Department of Bioengineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, PA 15261, USA.
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Merritt C, Maldonado P. Management of the Difficult Stoma. Surg Clin North Am 2024; 104:579-593. [PMID: 38677822 DOI: 10.1016/j.suc.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Fecal ostomy creation is a commonly performed procedure with many indications. Better outcomes occur when preoperative patient education and stoma site marking are provided. Despite a seemingly simple operation, ostomy creation is often difficult and complications are common. Certain risk factors, particularly obesity, are strongly associated with stoma-related complications. The ability to optimize the ostomy and stoma in the operating room and to troubleshoot frequently encountered post-operative stoma-related issues are critical skills for surgeons and ostomy nurses alike.
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Affiliation(s)
- Clay Merritt
- Department of Colon and Rectal Surgery, Alexander T. Augusta Military Medical Center, 9300 DeWitt Loop, Sunrise Pavilion, 2nd Floor, General Surgery Reception Desk, Fort Belvoir, VA 22060, USA.
| | - Paola Maldonado
- Wound Care Clinic, Alexander T. Augusta Military Medical Center, 9300 DeWitt Loop, Sunrise Pavilion, 2nd Floor, General Surgery Reception Desk, Fort Belvoir, VA 22060, USA
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Maldonado S, Lyons NB, Lall JS, Zimmerle JS, Rosamond B, Mills A, Seo YA, Calderon Rodriguez A, Coelho R, Cavagnaro N, Ali Z, Liang MK. Adequate Reporting Among Ventral Hernia Repair Operative Reports: A Cross-Sectional Study of Prevalence of Details and Association With Clinical Outcomes. ANNALS OF SURGERY OPEN 2024; 5:e425. [PMID: 38911660 PMCID: PMC11191853 DOI: 10.1097/as9.0000000000000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 03/26/2024] [Indexed: 06/25/2024] Open
Abstract
Objective We aimed to evaluate the prevalence of highly detailed ventral hernia repair (VHR) operative reports and associations between operative report detail and postoperative outcomes in a medico-legal dataset. Background VHR are one of the most common surgical procedures performed in the United States. Previous work has shown that VHR operative reports are poorly detailed, however, the relationship between operative report detail and patient outcomes is unknown. Methods This is a retrospective cross-sectional observational study. Operative reports describing VHR were obtained from a medical-legal database. Medical records were screened and data was extracted including clinical outcomes, such as surgical site infection (SSI), hernia recurrence, and reoperation and the presence of key details in each report. Highly detailed operative reports were defined as having 70% of recommended details. The primary outcome was the prevalence of highly detailed VHR operative reports. Results A total of 1011 VHR operative reports dictated by 693 surgeons across 517 facilities in 50 states were included. Median duration of follow-up was 4.6 years after initial surgery. Only 35.7% of operative reports were highly detailed. More recent operative reports, cases with resident involvement, and contaminated procedures were more likely to be highly detailed (all P < 0.05). Compared to poorly detailed operative reports, cases with highly detailed reports had fewer SSIs (13.2% vs 7.5%, P = 0.006), hernia recurrence (65.8% vs 55.4%, P = 0.002), and reoperation (78.9% vs 62.6%, P = 0.001). Conclusions In this medico-legal dataset, most VHR operative reports are poorly detailed while highly detailed operative reports were associated with lower rates of complications. Future studies should examine a nationally representative dataset to validate our findings.
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Affiliation(s)
- Said Maldonado
- From the Department of Clinical Sciences, Tillman J. Fertitta Family College of Medicine, University of Houston, Houston, TX
| | - Nicole B. Lyons
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Jonathan S. Lall
- From the Department of Clinical Sciences, Tillman J. Fertitta Family College of Medicine, University of Houston, Houston, TX
| | - J. Scott Zimmerle
- From the Department of Clinical Sciences, Tillman J. Fertitta Family College of Medicine, University of Houston, Houston, TX
| | - Brendan Rosamond
- From the Department of Clinical Sciences, Tillman J. Fertitta Family College of Medicine, University of Houston, Houston, TX
| | - Ashlynn Mills
- From the Department of Clinical Sciences, Tillman J. Fertitta Family College of Medicine, University of Houston, Houston, TX
| | - Yoolim Alex Seo
- From the Department of Clinical Sciences, Tillman J. Fertitta Family College of Medicine, University of Houston, Houston, TX
| | - Angelica Calderon Rodriguez
- From the Department of Clinical Sciences, Tillman J. Fertitta Family College of Medicine, University of Houston, Houston, TX
| | - Rainna Coelho
- Department of Surgery, Graduate Medical Education, HCA Healthcare Kingwood, Kingwood, TX
| | - Natalia Cavagnaro
- Department of Surgery, Graduate Medical Education, HCA Healthcare Kingwood, Kingwood, TX
| | - Zuhair Ali
- Department of Surgery, Graduate Medical Education, HCA Healthcare Kingwood, Kingwood, TX
| | - Mike K. Liang
- Department of Surgery, Graduate Medical Education, HCA Healthcare Kingwood, Kingwood, TX
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Bhardwaj P, Huayllani MT, Olson MA, Janis JE. Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors. JAMA Surg 2024; 159:651-658. [PMID: 38536183 PMCID: PMC10974689 DOI: 10.1001/jamasurg.2024.0233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/04/2023] [Indexed: 06/13/2024]
Abstract
Importance Recurrence is one of the most challenging adverse events after ventral hernia repair as it impacts quality of life, utilization of resources, and subsequent need for re-repair. Rates of recurrence range from 30% to 80% after ventral hernia repair. Objective To determine the contemporary ventral hernia recurrence rate over time in patients with previous hernia repair and to determine risk factors associated with recurrence. Design, Setting, and Participants This retrospective, population-based study used the Abdominal Core Health Quality Collaborative registry to evaluate year-over-year recurrence rates in patients with prior ventral hernia repair between January 2012 and August 2022. Patients who underwent at least 1 prior ventral hernia repair were included and categorized into 2 groups based on mesh or no-mesh use. There were 43 960 eligible patients; after exclusion criteria (patients with concurrent inguinal hernias as the primary diagnosis, nonstandard hernia procedure categories, American Society of Anesthesiologists class unassigned, or no follow-up), 29 834 patients were analyzed in the mesh group and 5599 in the no-mesh group. Main Outcomes and Measures Ventral hernia recurrence rates. Risk factors analyzed include age, body mass index, sex, race, insurance type, medical comorbidities, American Society of Anesthesiologists class, smoking, indication for surgery, concomitant procedure, hernia procedure type, myofascial release, fascial closure, fixation type, number of prior repairs, hernia width, hernia length, mesh width, mesh length, operative approach, prior mesh placement, prior mesh infection, mesh location, mesh type, postoperative surgical site occurrence, postoperative surgical site infection, postoperative seroma, use of drains, and reoperation. Results Among 29 834 patients with mesh, the mean (SD) age was 57.17 (13.36) years, and 14 331 participants (48.0%) were female. Among 5599 patients without mesh, the mean (SD) age was 51.9 (15.31) years, and 2458 participants (43.9%) were female. When comparing year-over-year hernia recurrence rates in patients with and without prior mesh repair, respectively, the Kaplan Meier analysis showed a recurrence rate of 201 cumulative events with 13 872 at risk (2.8%) vs 104 cumulative events with 1707 at risk (4.0%) at 6 months; 411 cumulative events with 4732 at risk (8.0%) vs 184 cumulative events with 427 at risk (32.6%) at 1 year; 640 cumulative events with 1518 at risk (19.7%) vs 243 cumulative events with 146 at risk (52.4%) at 2 years; 731 cumulative events with 670 at risk (29.3%) vs 258 cumulative events with 73 at risk (61.4%) at 3 years; 777 cumulative events with 337 at risk (38.5%) vs 267 cumulative events with 29 at risk (71.2%) at 4 years; and 798 cumulative events with 171 at risk (44.9%) vs 269 cumulative events with 19 at risk (73.7%) at 5 years. Higher body mass index; immunosuppressants; incisional and parastomal hernias; a robotic approach; greater hernia width; use of a biologic or resorbable synthetic mesh; and complications, such as surgical site infections and reoperation, were associated with higher odds of hernia recurrence. Conversely, greater mesh width, myofascial release, and fascial closure had lower odds of recurrence. Hernia type was the most important variable associated with recurrence. Conclusions and Relevance In this study, the 5-year recurrence rate after ventral hernia repair was greater than 40% and 70% in patients with and without mesh, respectively. Rates of ventral hernia recurrence increased over time, underscoring the importance of close, long-term follow up in this population.
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Affiliation(s)
- Priya Bhardwaj
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Maria T. Huayllani
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Molly A. Olson
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus
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Tang F, Miao D, Huang R, Zheng B, Yu Y, Ma P, Peng B, Li Y, Wang H, Wu D. Double-Layer Asymmetric Porous Mesh with Dynamic Mechanical Support Properties Enables Efficient Single-Stage Repair of Contaminated Abdominal Wall Defect. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2307845. [PMID: 38408735 DOI: 10.1002/adma.202307845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 02/08/2024] [Indexed: 02/28/2024]
Abstract
Contamination tolerance and long-term mechanical support are the two critical properties of meshes for contaminated abdominal wall defect repair. However, biological meshes with excellent pollution tolerance fail to provide bio-adaptive long-term mechanical support due to their rapid degradation. Here, a novel double-layer asymmetric porous mesh (SIS/PVA-EXO) is designed by simple and efficient in situ freeze-thaw of sticky polyvinyl alcohol (PVA) solution on the loosely porous surface of small intestinal submucosal decellularized matrix (SIS), which can successfully repair the contaminated abdominal wall defect with bio-adaptive dynamic mechanical support through only single-stage surgery. The exosome-loaded degradable loosely porous SIS layer accelerates the tissue healing; meanwhile, the exosome-loaded densely porous PVA layer can maintain long-term mechanical support without any abdominal adhesion. In addition, the tensile strength and strain at break of SIS/PVA-EXO mesh change gradually from 0.37 MPa and 210% to 0.10 MPa and 385% with the degradation of SIS layer. This unique performance can dynamically adapt to the variable mechanical demands during different periods of contaminated abdominal wall reconstruction. As a result, this SIS/PVA-EXO mesh shows an attractive prospect in the treatment of contaminated abdominal wall defect without recurrence by integrating local immune regulation, tissue remodeling, and dynamic mechanical supporting.
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Affiliation(s)
- Fuxin Tang
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Dongtian Miao
- PCFM Lab, School of Chemistry, Sun Yat-sen University, Guangzhou, 510006, P. R. China
| | - Rongkang Huang
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Bingna Zheng
- The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518000, P.R. China
| | - Yang Yu
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Pengwei Ma
- PCFM Lab, School of Chemistry, Sun Yat-sen University, Guangzhou, 510006, P. R. China
| | - Binying Peng
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Yong Li
- Department of General Surgery (Gastrointestinal Surgery), Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, P. R. China
| | - Hui Wang
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Dingcai Wu
- PCFM Lab, School of Chemistry, Sun Yat-sen University, Guangzhou, 510006, P. R. China
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You Y, Kim SU, Schweitzer J, Lee TH. The Great Debate: Mesh or No Mesh in Contaminated Hernia Repairs? Am Surg 2024:31348241256059. [PMID: 38770753 DOI: 10.1177/00031348241256059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Abdominal hernia surgeries are commonly performed with many different approaches, and mesh utilization has become a cornerstone in hernia repair, ensuring durable outcomes with minimal recurrence risk. However, managing contaminated hernia repairs presents unique challenges due to the heightened risks of mesh infection. Recent advancements in lightweight macroporous polypropylene meshes offer promising solutions. Studies have highlighted the superiority of macroporous polypropylene meshes compared to primary suture repair and other mesh types in terms of reduced surgical site infection rates and lower hernia recurrence rates. Moreover, utilizing macroporous polypropylene mesh in the retrorectus plane is associated with a favorable salvage rate, underscoring its efficacy in contaminated hernia repairs. At the same time, contrary evidence suggests higher postoperative complications with mesh use in settings of clean-contaminated or contaminated fields. Most significant complications are increased infection rates and similar recurrence rates compared to mesh-free repairs. New synthetic mesh that is being marketed as having better outcomes than other types of mesh and potentially primary repair need to be carefully assessed as biologic mesh once used to also be touted as the mesh to use in such fields, but more research is showing higher complication rates. The risk of infection and consequent morbidity might outweigh the benefit of less recurrence risk with mesh use. Further research, including prospective studies with long-term follow-up, is warranted to elucidate optimal hernia repair strategies in contaminated fields and inform evidence-based practice guidelines.
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Affiliation(s)
- Yuchen You
- General Surgery Department, Ventura County Medical Center, Ventura, CA, USA
| | - So Un Kim
- General Surgery Department, Arrowhead Regional Medical Center, Colton, CA, USA
| | - Jeremy Schweitzer
- General Surgery Department, Ventura County Medical Center, Ventura, CA, USA
| | - Tommy H Lee
- General Surgery Department, Arrowhead Regional Medical Center, Colton, CA, USA
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11
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Pogson-Morowitz K, Porras Fimbres D, Barrow BE, Oleck NC, Patel A. Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends. J Clin Med 2024; 13:2876. [PMID: 38792418 PMCID: PMC11122627 DOI: 10.3390/jcm13102876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field.
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Affiliation(s)
- Kaylyn Pogson-Morowitz
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, NC 27710, USA (A.P.)
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12
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Sun R, Lei L, Ji J, Chen Y, Tian W, Yang F, Huang Q. Designing a bi-layer multifunctional hydrogel patch based on polyvinyl alcohol, quaternized chitosan and gallic acid for abdominal wall defect repair. Int J Biol Macromol 2024; 263:130291. [PMID: 38378119 DOI: 10.1016/j.ijbiomac.2024.130291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/02/2024] [Accepted: 02/16/2024] [Indexed: 02/22/2024]
Abstract
In abdominal wall defect repair, surgical site infection (SSI) remains the primary cause of failure, while complications like visceral adhesions present significant challenges following patch implantation. We designed a Janus multifunctional hydrogel patch (JMP) with antibacterial, anti-inflammatory, and anti-adhesive properties. The patch comprises two distinct layers: a pro-healing layer and an anti-adhesion layer. The pro-healing layer was created by a simple mixture of polyvinyl alcohol (PVA), quaternized chitosan (QCS), and gallic acid (GA), crosslinked to form PVA/QCS/GA (PQG) hydrogels through GA's self-assembly effect and hydrogen bonding. Additionally, the PVA anti-adhesive layer was constructed using a drying-assisted salting method, providing a smooth and dense physical barrier to prevent visceral adhesion while offering essential mechanical support to the abdominal wall. The hydrogel patch demonstrates widely adjustable mechanical properties, exceptional biocompatibility, and potent antimicrobial properties, along with a sustained and stable release of antioxidants. In rat models of skin and abdominal wall defects, the JMP effectively promoted tissue healing by controlling infection, inhibiting inflammation, stimulating neovascularization, and successfully preventing the formation of visceral adhesions. These compelling results highlight the JMP's potential to improve the success rate of abdominal wall defect repair and reduce surgical complications.
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Affiliation(s)
- Ran Sun
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Lei Lei
- Affiliated Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
| | - Jiamin Ji
- Research Institute of General Surgery, Jinling Hospital, Southeast University, Nanjing, China
| | - Yuan Chen
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Weiliang Tian
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Fan Yang
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Qian Huang
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China.
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13
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Essani V, Maskal SM, Ellis RC, Messer N, Tu C, Miller BT, Petro CC, Beffa LRA, Krpata DM, Prabhu AS, Rosen MJ. Analysis of retromuscular drain output and postoperative outcomes for heavyweight versus mediumweight polypropylene mesh following open ventral hernia repair. Hernia 2024; 28:637-642. [PMID: 38409571 PMCID: PMC10997680 DOI: 10.1007/s10029-024-02972-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/21/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Heavyweight polypropylene (HWPP) mesh is thought to increase inflammatory response and delay tissue integration compared to mediumweight (MWPP). Reactive fluid volume (i.e., drain output) may be a reasonable surrogate for integration. We hypothesized that daily drain output is higher with HWPP compared to MWPP in open retromuscular ventral hernia repair (VHR). METHODS This is a post-hoc analysis of a multicenter, randomized clinical trial conducted March 2017-April 2019 comparing MWPP and HWPP for VHR. Retromuscular drain output in milliliters was measured at 24-h intervals up to postoperative day seven. Univariate analyses compared differences in daily drain output and time to drain removal. Multivariable analyses compared total drain output and wound morbidity within 30 days and hernia recurrence at 1 year. RESULTS 288 patients were included; 140 (48.6%) HWPP and 148 (51.4%) MWPP. Daily drain output for days 1-3 was higher for HWPP vs. MWPP (total volume: 837.8 mL vs. 656.5 mL) (p < 0.001), but similar on days 4-7 (p > 0.05). Median drain removal time was 5 days for both groups. Total drain output was not predictive of 30-day wound morbidity (p > 0.05) or hernia recurrence at 1 year (OR 1, p = 0.29). CONCLUSION While HWPP mesh initially had higher drain outputs, it rapidly returned to levels similar to MWPP by postoperative day three and there was no difference in clinical outcomes. We believe that drains placed around HWPP mesh can be managed similarly to MWPP mesh.
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Affiliation(s)
- V Essani
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - S M Maskal
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA.
| | - R C Ellis
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - N Messer
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - C Tu
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - B T Miller
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - L R A Beffa
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
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Diab MM, Patel S, Young C, Allen IE, Harris HW. Quality of life measures and cost analysis of biologic versus synthetic mesh for ventral hernia repair: The Preventing Recurrence in Clean and Contaminated Hernias randomized clinical trial. Surgery 2024; 175:1063-1070. [PMID: 38135553 DOI: 10.1016/j.surg.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/11/2023] [Accepted: 11/07/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Although the most durable method for ventral hernia repairs involves using mesh, whether to use biologic mesh versus synthetic mesh remains controversial. This study aimed to compare synthetic and biologic meshes with respect to patient-reported quality of life scores and costs after ventral hernia repair surgeries. METHODS This study is part of the Preventing Recurrence in Clean and Contaminated Hernias (PRICE) pragmatic randomized control trial conducted from March 2014 through October 2018. Patients were randomized 1:1 to undergo ventral hernia repair using either a biologic or synthetic mesh. The coprimary outcomes were 2-year changes in Visual Analog Scale, Activities Assessment Scale, Hernia-Related Quality-of-Life Survey, and Short-Form 36 Health Survey (SF-36) quality-of-life scores from repair. The secondary outcome was the overall cost per patient. RESULTS Among the 165 patients included in the study, 82 were randomized to biologic meshes and 83 to synthetic meshes. There were no significant differences in the performance between the 2 mesh types with regard to quality-of-life measures using a mixed model approach. This result was consistent even when performing subgroup analysis based on wound contamination. However, nonparametric tests comparing the differences in quality-of-life measures from preoperative to 24-month postoperative timepoints revealed that the synthetic mesh group showed a greater reduction in disability than biologic mesh for the SF-36 (median [interquartile range] of 20 [5-30] vs 6 [1-20], P = .025). This difference was due to reductions in the physical role limitations (62 [0-100] vs 0 [0-50], P = .018) and the pain (38 [12-50] vs 12 [0-25], P = .012) domains of the SF-36. Overall cost per patient was greater for biologic meshes (mean [95% confidence interval] of $80,420 [$66,485-$94,355] vs $61,036 [$48,946-$73,125], P = .038), regardless of insurance type. CONCLUSION In this randomized clinical trial, there were no differences in changes in quality-of-life scores at the 2-year timepoint except for the SF-36, where the synthetic mesh may be associated with less pain and physical role limitations than the biologic mesh. Overall costs per patient were less for synthetic than biologic mesh.
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Affiliation(s)
- Mohamed Mustafa Diab
- Department of Surgery, University of California, San Francisco, CA; Department of Surgery, Duke University, Durham, NC
| | - Sohil Patel
- Department of Surgery, University of California, San Francisco, CA
| | - Charlotte Young
- Department of Surgery, University of California, San Francisco, CA
| | - Isabel Elaine Allen
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA
| | - Hobart W Harris
- Department of Surgery, University of California, San Francisco, CA.
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15
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Ahmed A, Gandhi S, Ganam S, Diab ARF, Mhaskar R, Sujka J, DuCoin C, Docimo S. Ventral hernia repair using bioresorbable poly-4-hydroxybutyrate mesh in clean and contaminated surgical fields: a systematic review and meta-analysis. Hernia 2024; 28:575-584. [PMID: 38345668 DOI: 10.1007/s10029-023-02951-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/16/2023] [Indexed: 04/06/2024]
Abstract
PURPOSE Use of biologic or synthetic mesh in hernia repair shifts is based on evolving evidence. Poly-4-hydroxybutyrate (P4HB) biosynthetic mesh is a potential alternative to biologic and synthetic mesh in ventral hernia repair (VHR). This meta-analysis assesses the efficacy of P4HB mesh in clean and contaminated surgical settings. METHODS Two authors searched literature on PubMed, reviewing titles and abstracts of all articles to determine inclusion eligibility. Post-operative data were compared via transformation method to convert the proportion of patients with the outcome of interest into a suitable quantity for random-effects synthesis using STATA software. RESULTS Initial search yielded 287 citations. Six studies were included and categorized on whether hernia repairs were conducted in clean (CDC class I) or contaminated cases (CDC class II-IV). The pooled proportion of surgical site infection (SSI), surgical site occurrence (SSO), hernia recurrence, total surgical complications, and reoperation were calculated in 391 clean and 81 contaminated cases. For clean vs. contaminated cases, the following pooled proportions were noted: SSI (2% (CI 0-7%) vs 9% (CI 0-025) (p = 0.03), SSO: 14% (CI 5-25%) vs 35% (CI 22-50%) (p = 0.006), hernia recurrence (8% (CI 1-19%) vs 4% (CI 0-12%) (p = 0.769); surgical complications (17% (CI 6-32%) vs 50% (CI 27-72%) (p = 0.009). Reoperation data were available in 298 clean cases across four studies: 5% (CI 0-15%). CONCLUSIONS P4HB biosynthetic mesh may be more effective than previously thought, particularly in clean wounds. P4HB may also be superior to biologic mesh when compared to clinical trial data. Further research is necessary for more direct comparison.
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Affiliation(s)
- A Ahmed
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - S Gandhi
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - S Ganam
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - A-R F Diab
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - R Mhaskar
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - J Sujka
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - C DuCoin
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - S Docimo
- University of South Florida Morsani College of Medicine, Tampa, FL, USA.
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA.
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16
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Lemdani MS, Niu EF, Amro C, Gala Z, Ewing JN, Honig SE, Broach RB, Fischer JP. Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields. Ann Plast Surg 2024; 92:S156-S160. [PMID: 38556666 DOI: 10.1097/sap.0000000000003860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh. MATERIALS METHODS Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed. RESULTS Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m2, and a defect size of 356.9 ± 227.7 cm2. Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications. CONCLUSIONS Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.
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Affiliation(s)
- Mehdi S Lemdani
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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17
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Huang EY, Broderick RC, Spurzem GJ, Li JZ, Blitzer RR, Cheverie JN, Sandler BJ, Horgan S, Jacobsen GR. Long-term outcomes of PGA-TMC absorbable synthetic scaffold in both clean and contaminated ventral hernia repairs. Surg Endosc 2024; 38:2231-2239. [PMID: 38498213 DOI: 10.1007/s00464-024-10777-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Biosynthetic meshes afford the cost advantages of being made from fully synthetic material, but are also biodegradable, making them a versatile option that can be used in both clean and contaminated cases. The aim of this study is to evaluate the safety profile and long-term outcomes of using GORE BIO-A (BIO-A) as an adjunct to abdominal wall reconstruction in all wound classes. METHODS A retrospective review identified patients undergoing abdominal hernia repair using BIO-A from October 2008 to June 2018. The primary outcome was hernia recurrence rate. Only patients with at least 6-month follow-up were included when looking at recurrence rates. Secondary outcomes included 30-day morbidity categorized according to CDC Surgical Site Infection Criteria, return to operating/procedure room (RTOR), 30-day readmission, length of stay (LOS), and mortality. RESULTS A total of 207 patients were identified, CDC Wound Classification breakdown was 127 (61.4%), 41 (19.8%), 14 (6.8%), and 25 (12.1%) for wound classes I, II, III, and IV, respectively. Median follow-up was 55.4 months (range 0.2-162.4). Overall recurrence rate was 17.4%. Contaminated cases experienced higher recurrence rates (28.8% versus 10.4%, p = 0.002) at a mean follow up of 46.9 and 60.8 months for contaminated and clean patients, respectively. Recurrent patients had higher BMI (32.4 versus 28.4 kg/m2, p = 0.0011), larger hernias (162.2 versus 106.7 cm2, p = 0.10), higher LOS (11.1 versus 5.6 days, p = 0.0051), and higher RTOR rates (16.7% versus 5.6%, p = 0.053). 51 (24.5%) patients experienced some morbidity, including 19 (9.2%) surgical site occurences, 7 (3.4%) superficial surgical site infections, 16 (7.7%) deep surgical site infections, and 1 (0.5%) organ space infection. CONCLUSION This study affirms the use of biosynthetic mesh as a cost-effective alternative in all wound classifications, yielding good outcomes, limited long-term complications, and low recurrence. rates.
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Affiliation(s)
- Estella Y Huang
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Graham J Spurzem
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA.
| | - Jonathan Z Li
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Rachel R Blitzer
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Joslin N Cheverie
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
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18
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Sweitzer K, O'Shea A, Tawil C, Weissberg J, Tomtschik J, Butterfield J, Fowler C, Langstein H, Bell D. Hernia Recurrence and Complications After Abdominal Reconstruction With Reinforced Versus Nonreinforced Biologic Mesh. Ann Plast Surg 2024; 92:S196-S199. [PMID: 38556672 DOI: 10.1097/sap.0000000000003875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Both biologic and permanent (synthetic) meshes are used for abdominal wall reconstruction. Biologic mesh has the advantage of eventual incorporation, which makes it generally preferred in contaminated patients compared with synthetic mesh (Ann Surg. 2013;257:991-996). However, synthetic mesh has been shown to have decreased long-term hernia recurrence despite increased complications (JAMA Surg. 2022;157:293-301). Ovitex (TelaBio, Ltd, Auckland, New Zealand) is a combined reinforced biologic mesh with a permanent Prolene suture weave that theoretically combines incorporation with a long-term strength component. We hypothesize that a reinforced biologic will have a similar complication profile but decreased long-term hernia recurrence. METHODS A single-center retrospective review was performed from January 2013 to January 2022. Baseline patient characteristics and outcomes including 90-day complications and recurrence were compared. Categorical and continuous variables were analyzed with χ2 and Wilcoxon rank sum tests, respectively. Predictors of postoperative complications and hernia recurrence were analyzed via univariate logistic regression and multivariate logistic regression with backward stepwise selection with a threshold of P < 0.2. RESULTS Two hundred fifty-four patients underwent abdominal wall reconstruction biologic mesh (Strattice, Allergan; FlexHD, MTF Biologics; Alloderm, Allergan; Surgisis Gold, Cook Biotech; Ovitex, Telabio) with retrorectus (66.5%) or intraperitoneal (33.5%) mesh placement. Sixty-six of these used reinforced biologic mesh (Ovitex, TelaBio). Baseline characteristics were comparable including preoperative hernia size measured on CT. The mean follow-up time was 343 days. The majority of patients underwent component separation (80.3% bilateral, 11.4% unilateral, 8.3% none). On univariate analysis, reinforced biologic mesh did not impact 90-day complication rates (P = 0.391) or hernia recurrence rates (P = 0.349). On multivariate analysis, reinforced mesh had no impact on complication or recurrence rates (P > 0.2). A previous history of infected mesh was an independent risk factor for hernia recurrence (P = 0.019). Nonreinforced biologics were more likely to be used in instances of previous mesh infection (P = 0.025), bowel resection (P = 0.026), and concomitantly at the time of stoma takedown (P = 0.04). Reinforced biologics were more likely to be used with a history of previous hernia repair with recurrence not due to infection (P = 0.001). Body mass index >35 was an independent risk factor across both groups for 90-day complications (P = 0.028). CONCLUSIONS Reinforced versus nonreinforced biologics have similar risk profile and recurrence rate when placed primary fascial repair achieved. In abdominal walls with history of infection, or abdominal wall reconstruction performed concomitantly at the time of stoma takedown or bowel resection/anastomosis, nonreinforced biologics were used more commonly with no difference in negative outcomes. This implies that they may have a role for use in contaminated surgical cases. Reinforced biologics were more commonly used as a mesh choice in the setting of previous hernia repair with recurrence with no difference in outcomes. This implies that the reinforced nature may be useful in situations where extra reinforcement of already traumatized abdominal wall tissue is needed. Retrorectus or intraperitoneal placement of any biologic mesh is acceptable and should be chosen based off surgeon comfort and anticipated cost saving of individual mesh brands. There may be a role for reinforced mesh in the setting of previous failed hernia repair with weakened fascia, as well as nonreinforced in contaminated cases.
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Affiliation(s)
- Keith Sweitzer
- From the Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, NY
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Maskal S, Chang J, Ellis R, Messer N, Melland-Smith M, Tu C, Miller B, Petro C, Simon R, Prabhu A, Rosen M, Beffa L. Abdominal wall mass resections: single-center closure practices and outcomes following oncologic resections of abdominal wall fascia. Hernia 2024; 28:457-464. [PMID: 38062203 DOI: 10.1007/s10029-023-02928-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/05/2023] [Indexed: 04/06/2024]
Abstract
PURPOSE Radical resections for abdominal wall tumors are rare, thus yielding limited data on reconstruction of defects. We describe surgical management and long-term outcomes following radical tumor resection. METHODS This was a single-center retrospective review of patients between January 2010 and December 2022. Variables included operative characteristics, wound complications, hernia development, tumor recurrence, and reoperation. A multivariable analysis compared wound morbidity for suture and mesh repairs while adjusting for defect width, fascial closure, and CDC wound class. RESULTS 120 patients were identified. Mean follow-up was 3.9 ± 3.4 years. Seventy-five (62.5%) of the masses were primary; most commonly desmoid (n = 25) and endometrioma (n = 27). Forty-five masses were metastases. Mean tumor width was 6.2 ± 3.4 cm; mean defect width was 8.1 ± 4.1 cm. Sixty-one patients (50.8%) had mesh placed, with variation in technique. Postoperative CT scans were available for 88 (73.3%) patients. Forty SSOs (33.3%), 11 SSIs (9.2%), and 18 (15%) SSOPIs occurred within 30 days. On multivariable analysis, increased defect width was associated with SSOPI (OR 1.17, p = 0.041) and CDC wound class II-III was associated with SSI (OR 8.38 and 49.1, p < 0.05) and SSOPI (OR 5.77 and 17.4, p < 0.05); mesh was not associated with these outcomes. Seven patients (5.8%) underwent 30-day reoperations and 35 (20.8%) required additional operations after 30 days. Thirteen percent developed abdominal wall (n = 8) or intra-abdominal tumor recurrence (n = 8) requiring reoperation. Twenty-seven (22.5%) patients developed hernias with a mean fascial defect width of 9.8 ± 7.2 cm. CONCLUSION Abdominal wall mass resections are morbid, often contaminated cases with high postoperative complication rates. Risks and benefits of mesh implantation should be tailored on an individual basis.
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Affiliation(s)
- S Maskal
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA.
| | - J Chang
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - R Ellis
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - N Messer
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - M Melland-Smith
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - C Tu
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - B Miller
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - C Petro
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - R Simon
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - A Prabhu
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - M Rosen
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
| | - L Beffa
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, A-100, Cleveland, OH, 44106, USA
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20
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Tran DH, Rubarth C, Leeds SG, Fair L, McGowan T, Ramakrishnan S, Shabbir R, Ogola G, Ward MA, Aladegbami B. The use of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh in ventral hernia repair: a systematic review and meta-analysis. Hernia 2024:10.1007/s10029-024-02996-z. [PMID: 38512507 DOI: 10.1007/s10029-024-02996-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/18/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE/BACKGROUND Despite the growing use of bioabsorbable mesh in ventral hernia repairs (VHR), the evidence of its impact on patient outcomes remains limited. This study aims to investigate the efficacy and safety profile of poly-4-hydroxybutyrate (P4HB) mesh for ventral hernia repair through a systematic review and meta-analysis. METHODS A literature search of five databases (PubMed, Embase, Ovid, Medline, and Google Scholar) produced a list of publications that analyzed the use of P4HB mesh in ventral hernia repair in both clean and contaminated cases. The primary postoperative outcomes of hernia recurrence, surgical site infections (SSI), and any complications were analyzed through a pooled meta-analysis. RESULTS In our systematic review, 21 studies met the inclusion criteria with a total of 1858 patients (933 males and 925 females) and an average age of 56.8 years. The median follow-up ranged from 1.6 to 62.3 months. In our meta-analysis, the use of P4HB mesh in VHR in proportion of events demonstrated a recurrence rate of 9% [6%; 15%], SSI of 10% [6%; 16%] and 35% [9%; 42%] for rate of any complications. Sub-meta-analysis restricted to studies with follow up > 18 months continues to show low rates of recurrence of 9% (95%CI, 4-17%), SSI of 9% (95%CI, 4-16%), and 31% (95%CI, 23-41%) for any complications. CONCLUSION Our study demonstrates that the use of P4HB mesh is both safe and effective in ventral hernia repairs. When further analyzed past 18 months, the time where P4HB mesh fully resorbs, the rates of hernia recurrence, SSI, and any complications remain low of upwards of 5 years and comparable to the rates seen in synthetic and biologics in similar patient populations.
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Affiliation(s)
- Daniel H Tran
- Texas A&M College of Medicine, Bryan, TX, USA
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Charles Rubarth
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Steven G Leeds
- Texas A&M College of Medicine, Bryan, TX, USA
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
| | - Luke Fair
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
| | - Titus McGowan
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | | | - Rehma Shabbir
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Gerald Ogola
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Marc A Ward
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
| | - Bola Aladegbami
- Texas A&M College of Medicine, Bryan, TX, USA.
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA.
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA.
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21
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Kaveti R, Lee JH, Youn JK, Jang TM, Han WB, Yang SM, Shin JW, Ko GJ, Kim DJ, Han S, Kang H, Bandodkar AJ, Kim HY, Hwang SW. Soft, Long-Lived, Bioresorbable Electronic Surgical Mesh with Wireless Pressure Monitor and On-Demand Drug Delivery. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2307391. [PMID: 37770105 DOI: 10.1002/adma.202307391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/02/2023] [Indexed: 10/03/2023]
Abstract
Current research in the area of surgical mesh implants is somewhat limited to traditional designs and synthesis of various mesh materials, whereas meshes with multiple functions may be an effective approach to address long-standing challenges including postoperative complications. Herein, a bioresorbable electronic surgical mesh is presented that offers high mechanical strength over extended timeframes, wireless post-operative pressure monitoring, and on-demand drug delivery for the restoration of tissue structure and function. The study of materials and mesh layouts provides a wide range of tunability of mechanical and biochemical properties. Dissolvable dielectric composite with porous structure in a pyramidal shape enhances sensitivity of a wireless capacitive pressure sensor, and resistive microheaters integrated with inductive coils provide thermo-responsive drug delivery system for an antibacterial agent. In vivo evaluations demonstrate reliable, long-lived operation, and effective treatment for abdominal hernia defects, by clear evidence of suppressed complications such as adhesion formation and infections.
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Affiliation(s)
- Rajaram Kaveti
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Joong Hoon Lee
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
- SK Hynix Co., Ltd., 2091, Gyeongchung-daero, Bubal-eup, Incheon, Gyeonggi-do, 17336, Republic of Korea
| | - Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Tae-Min Jang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Won Bae Han
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Seung Min Yang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
- Hanwha Systems Co., Ltd., 188, Pangyoyeok-Ro, Bundang-Gu, Seongnam-si, Gyeonggi-do, 13524, Republic of Korea
| | - Jeong-Woong Shin
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Gwan-Jin Ko
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Dong-Je Kim
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Sungkeun Han
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Heeseok Kang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Amay J Bandodkar
- Department of Electrical and Computer Engineering, North Carolina State University, Raleigh, NC, 27606, USA
- Center for Advanced Self-Powered Systems of Integrated Sensors and Technologies (ASSIST), North Carolina State University, Raleigh, NC, 27606, USA
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Suk-Won Hwang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
- Department of Integrative Energy Engineering, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
- Center for Biomaterials, Biomedical Research Institute, Korea Institute of Science and Technology (KIST), 5 Hwarang-ro 14-gil, Seongbuk-gu, Seoul, 02792, Republic of Korea
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22
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Maskal SM, Thomas JD, Miller BT, Fafaj A, Zolin SJ, Montelione K, Ellis RC, Prabhu AS, Krpata DM, Beffa LRA, Costanzo A, Zheng X, Rosenblatt S, Rosen MJ, Petro CC. Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial. Surgery 2024; 175:813-821. [PMID: 37770344 DOI: 10.1016/j.surg.2023.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/14/2023] [Accepted: 06/18/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days. METHODS This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications. RESULTS A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days. CONCLUSION Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio.
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Affiliation(s)
- Sara M Maskal
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Aldo Fafaj
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | | | | | - Ryan C Ellis
- Cleveland Clinic, Department of Surgery, Cleveland, OH
| | - Ajita S Prabhu
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/aprabhumd1
| | - David M Krpata
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/DKrpataMD
| | - Lucas R A Beffa
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/BeffaLukeMD
| | | | | | | | - Michael J Rosen
- Cleveland Clinic, Department of Surgery, Cleveland, OH. https://twitter.com/MikeRosen
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Kirkpatrick AW, Coccolini F, Tolonen M, Minor S, Catena F, Celotti A, Gois E, Perrone G, Novelli G, Garulli G, Ioannidis O, Sugrue M, De Simone B, Tartaglia D, Lampella H, Ferreira F, Ansaloni L, Parry NG, Colak E, Podda M, Noceroni L, Vallicelli C, Rezende-Netos J, Ball CG, McKee J, Moore EE, Mather J. Are Surgeons Going to Be Left Holding the Bag? Incisional Hernia Repair and Intra-Peritoneal Non-Absorbable Mesh Implant Complications. J Clin Med 2024; 13:1005. [PMID: 38398318 PMCID: PMC10889414 DOI: 10.3390/jcm13041005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Ventral incisional hernias are common indications for elective repair and frequently complicated by recurrence. Surgical meshes, which may be synthetic, bio-synthetic, or biological, decrease recurrence and, resultingly, their use has become standard. While most patients are greatly benefited, mesh represents a permanently implanted foreign body. Mesh may be implanted within the intra-peritoneal, preperitoneal, retrorectus, inlay, or onlay anatomic positions. Meshes may be associated with complications that may be early or late and range from minor to severe. Long-term complications with intra-peritoneal synthetic mesh (IPSM) in apposition to the viscera are particularly at risk for adhesions and potential enteric fistula formation. The overall rate of such complications is difficult to appreciate due to poor long-term follow-up data, although it behooves surgeons to understand these risks as they are the ones who implant these devices. All surgeons need to be aware that meshes are commercial devices that are delivered into their operating room without scientific evidence of efficacy or even safety due to the unique regulatory practices that distinguish medical devices from medications. Thus, surgeons must continue to advocate for more stringent oversight and improved scientific evaluation to serve our patients properly and protect the patient-surgeon relationship as the only rationale long-term strategy to avoid ongoing complications.
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Affiliation(s)
- Andrew W. Kirkpatrick
- Regional Trauma Services, Department of Surgery, Critical Care Medicine, University of Calgary, Calgary, AB T2N 2T9, Canada
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, University of Calgary, Calgary, AB T3H 3W8, Canada
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, 56124 Pisa, Italy;
| | - Matti Tolonen
- Emergency Surgery Department, HUS Helsinki University Hospital, 00029 Helsinki, Finland;
| | - Samual Minor
- Department of Surgery and Critical Care Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Fausto Catena
- Head Emergency and General Surgery Department, Bufalini Hospital, 47521 Cesena, Italy; (F.C.); (C.V.)
| | | | - Emanuel Gois
- Department of Surgery, Londrina State University, Londrina 86038-350, Brazil;
| | - Gennaro Perrone
- Department of Emergency Surgery, Parma University Hospital, 43125 Parma, Italy;
| | - Giuseppe Novelli
- Chiurgia Generale e d’Urgenza, Osepedale Buffalini Hospital, 47521 Cesna, Italy;
| | | | - Orestis Ioannidis
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital “George Papanikolaou”, 57010 Thessaloniki, Greece;
| | - Michael Sugrue
- Letterkenny University Hospital, F92 AE81 Donegal, Ireland;
| | - Belinda De Simone
- Unit of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve-Saint-Georges, 91560 Villeneuve-Saint-Georges, France;
| | - Dario Tartaglia
- Emergency and General Surgery Unit, New Santa Chiara Hospital, University of Pisa, 56126 Pisa, Italy;
| | - Hanna Lampella
- Gastrointestinal Surgery Unit, Helsinki University Hospital, Helsinki University, 00100 Helsinki, Finland;
| | - Fernando Ferreira
- GI Surgery and Complex Abdominal Wall Unit, Hospital CUF Porto, Faculty of Medicine of the Oporto University, 4200-319 Porto, Portugal;
| | - Luca Ansaloni
- San Matteo Hospital of Pavia, University of Pavia, 27100 Pavia, Italy;
| | - Neil G. Parry
- Department of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada;
| | - Elif Colak
- Samsun Training and Research Hospital, University of Samsun, 55000 Samsun, Turkey;
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, 09124 Cagliari, Italy;
| | - Luigi Noceroni
- Hospital Infermi Rimini, 47923 Rimini, Italy; (G.G.); (L.N.)
| | - Carlo Vallicelli
- Head Emergency and General Surgery Department, Bufalini Hospital, 47521 Cesena, Italy; (F.C.); (C.V.)
| | - Joao Rezende-Netos
- Trauma and Acute Care Surgery, General Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON M5T 1P8, Canada;
| | - Chad G. Ball
- Acute Care, and Hepatobiliary Surgery and Regional Trauma Services, University of Calgary, Calgary, AB T2N 1N4, Canada; (C.G.B.); (J.M.)
| | - Jessica McKee
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, University of Calgary, Calgary, AB T3H 3W8, Canada
| | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO 80204, USA;
| | - Jack Mather
- Acute Care, and Hepatobiliary Surgery and Regional Trauma Services, University of Calgary, Calgary, AB T2N 1N4, Canada; (C.G.B.); (J.M.)
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24
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Wang X, Liu C, Li X, Shen T, Lian J, Shi J, Jiang Z, Qiu G, Wang Y, Meng E, Wei G. A novel electrospun polylactic acid silkworm fibroin mesh for abdominal wall hernia repair. Mater Today Bio 2024; 24:100915. [PMID: 38188648 PMCID: PMC10767193 DOI: 10.1016/j.mtbio.2023.100915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 01/09/2024] Open
Abstract
Objective Abdominal wall hernias are common abdominal diseases, and effective hernia repair is challenging. In clinical practice, synthetic meshes are widely applied for repairing abdominal wall hernias. However, postoperative complications, such as inflammation and adhesion, are prevalent. Although biological meshes can solve this problem to a certain extent, they face the problems of heterogeneity, rapid degradation rate, ordinary mechanical properties, and high-cost. Here, a novel electrospinning mesh composed of polylactic acid and silk fibroin (PLA-SF) for repairing abdominal wall hernias was manufactured with good physical properties, biocompatibility and low production cost. Materials and methods FTIR and EDS were used to demonstrate that the PLA-SF mesh was successfully synthesized. The physicochemical properties of PLA-SF were detected by swelling experiments and in vitro degradation experiments. The water contact angle reflected the hydrophilicity, and the stress‒strain curve reflected the mechanical properties. A rat abdominal wall hernia model was established to observe degradation, adhesion, and inflammation in vivo. In vitro cell mesh culture experiments were used to detect cytocompatibility and search for affected biochemical pathways. Results The PLA-SF mesh was successfully synthesized and did not swell or degrade over time in vitro. It had a high hydrophilicity and strength. The PLA-SF mesh significantly reduced abdominal inflammation and inhibited adhesion formation in rat models. The in vitro degradation rate of the PLA-SF mesh was slower than that of tissue remodeling. Coculture experiments suggested that the PLA-SF mesh reduced the expression of inflammatory factors secreted by fibroblasts and promoted fibroblast proliferation through the TGF-β1/Smad pathway. Conclusion The PLA-SF mesh had excellent physicochemical properties and biocompatibility, promoted hernia repair of the rat abdominal wall, and reduced postoperative inflammation and adhesion. It is a promising mesh and has potential for clinical application.
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Affiliation(s)
- Xingjie Wang
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Changjun Liu
- School of Life and Health Sciences, Hunan University of Science and Technology, Xiangtan, 411201, Hunan, China
| | - Xuqi Li
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Tianli Shen
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Jie Lian
- Department of Pathology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Jing Shi
- Department of Respiratory and Endocrinology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Zhengdong Jiang
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Guanglin Qiu
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yuanbo Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Er Meng
- School of Life and Health Sciences, Hunan University of Science and Technology, Xiangtan, 411201, Hunan, China
| | - Guangbing Wei
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
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25
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Harrell KN, Grimes AD, Gill H, Reynolds JK, Ueland WR, Sciarretta JD, Todd SR, Trust MD, Ngoue M, Thomas BW, Ayuso SA, LaRiccia A, Spalding MC, Collins MJ, Collier BR, Karam BS, de Moya MA, Lieser MJ, Chipko JM, Haan JM, Lightwine KL, Cullinane DC, Falank CR, Phillips RC, Kemp MT, Alam HB, Udekwu PO, Sanin GD, Hildreth AN, Biffl WL, Schaffer KB, Marshall G, Muttalib O, Nahmias J, Shahi N, Moulton SL, Maxwell RA. A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias. Injury 2024; 55:111204. [PMID: 38039636 DOI: 10.1016/j.injury.2023.111204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 11/01/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.
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Affiliation(s)
- Kevin N Harrell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States.
| | | | - Harkanwar Gill
- University of Oklahoma, Oklahoma City, OK, United States
| | | | - Walker R Ueland
- University of Kentucky School of Medicine, Lexington, KY, United States
| | | | | | - Marc D Trust
- University of Texas at Austin, Austin, TX, United States
| | - Marielle Ngoue
- University of Texas at Austin, Austin, TX, United States
| | - Bradley W Thomas
- Atrium Health Carolinas Medical Center, Charlotte, NC, United States
| | - Sullivan A Ayuso
- Atrium Health Carolinas Medical Center, Charlotte, NC, United States
| | | | | | | | | | - Basil S Karam
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Marc A de Moya
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Mark J Lieser
- Research Medical Center, Kansas City, MO, United States
| | - John M Chipko
- Research Medical Center, Kansas City, MO, United States
| | - James M Haan
- Ascension Via Christi on St. Francis Hospital, Wichita, KS, United States
| | - Kelly L Lightwine
- Ascension Via Christi on St. Francis Hospital, Wichita, KS, United States
| | | | | | | | | | - Hasan B Alam
- University of Michigan, Ann Arbor, MI, United States
| | | | - Gloria D Sanin
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Amy N Hildreth
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, La Jolla, CA, United States
| | | | - Gary Marshall
- Medical City Plano Hospital, Plano, TX, United States
| | - Omaer Muttalib
- University of California, Irvine, Orange, CA, United States
| | - Jeffry Nahmias
- University of California, Irvine, Orange, CA, United States
| | - Niti Shahi
- Children's Hospital Colorado, Denver, CO, United States
| | | | - Robert A Maxwell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States
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26
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Kumar S, Singh J, Sundaramurthi S. Recurrence in ventral abdominal wall hernias treated using semiabsorbable hybrid meshes. Updates Surg 2024; 76:325-326. [PMID: 37782402 DOI: 10.1007/s13304-023-01635-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 08/16/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Sanjana Kumar
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Jaiveer Singh
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sudharsanan Sundaramurthi
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
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Bloemendaal ALA. Robotic Retromuscular (Recurrent) Parastomal Hernia Repair (r-Pauli-Repair) With Synthetically Reinforced Biological Mesh; Technique, Early Experience, and Short-Term Follow-Up. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:12059. [PMID: 38312416 PMCID: PMC10831679 DOI: 10.3389/jaws.2023.12059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/30/2023] [Indexed: 02/06/2024]
Abstract
Introduction: Parastomal hernia repair remains a challenge. We describe a robotic retromuscular non-keyhole mesh repair using a synthetically reinforced biological mesh (Ovitex) for the repair of complex and/or recurrent parastomal hernia and technical modifications we made along the way to improve our technique. Methods: All patients underwent the described retromuscular parastomal hernia repair. Data was collected in a database and a retrospective analysis was performed on direct postoperative results and early follow-up. Results: Eleven patients underwent the operation. Median follow-up was 12 months. Median LOS was 6 days. Two recurrences occurred. One patient suffered postoperative hematoma and skin necrosis, which healed completely, but did lead to a recurrence. One patient had a significant seroma, which subsided without intervention. Both recurrences were reoperated, and a local repair was performed. Conclusion: This paper is the first to describe a modified robotic Pauli repair for complex and recurrent parastomal hernia, using a synthetically reinforced biological mesh. Results are satisfying so far, especially considering the complexity of the cases.
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Najm A, Niculescu AG, Gaspar BS, Grumezescu AM, Beuran M. A Review of Abdominal Meshes for Hernia Repair-Current Status and Emerging Solutions. MATERIALS (BASEL, SWITZERLAND) 2023; 16:7124. [PMID: 38005054 PMCID: PMC10672379 DOI: 10.3390/ma16227124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023]
Abstract
Abdominal hernias are common issues in the clinical setting, burdening millions of patients worldwide. Associated with pain, decreased quality of life, and severe potential complications, abdominal wall hernias should be treated as soon as possible. Whether an open repair or laparoscopic surgical approach is tackled, mesh reinforcement is generally required to ensure a durable hernia repair. Over the years, numerous mesh products have been made available on the market and in clinical settings, yet each of the currently used meshes presents certain limitations that reflect on treatment outcomes. Thus, mesh development is still ongoing, and emerging solutions have reached various testing stages. In this regard, this paper aims to establish an up-to-date framework on abdominal meshes, briefly overviewing currently available solutions for hernia repair and discussing in detail the most recent advances in the field. Particularly, there are presented the developments in lightweight materials, meshes with improved attachment, antimicrobial fabrics, composite and hybrid textiles, and performant mesh designs, followed by a systematic review of recently completed clinical trials.
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Affiliation(s)
- Alfred Najm
- Department of Surgery, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari, Sector 5, 050474 Bucharest, Romania; (A.N.); (B.S.G.); (M.B.)
- Emergency Hospital Floreasca Bucharest, 8 Calea Floresca, Sector 1, 014461 Bucharest, Romania
| | - Adelina-Gabriela Niculescu
- Research Institute of the University of Bucharest—ICUB, University of Bucharest, 050657 Bucharest, Romania;
- Department of Science and Engineering of Oxide Materials and Nanomaterials, Politehnica University of Bucharest, 011061 Bucharest, Romania
| | - Bogdan Severus Gaspar
- Department of Surgery, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari, Sector 5, 050474 Bucharest, Romania; (A.N.); (B.S.G.); (M.B.)
- Emergency Hospital Floreasca Bucharest, 8 Calea Floresca, Sector 1, 014461 Bucharest, Romania
| | - Alexandru Mihai Grumezescu
- Research Institute of the University of Bucharest—ICUB, University of Bucharest, 050657 Bucharest, Romania;
- Department of Science and Engineering of Oxide Materials and Nanomaterials, Politehnica University of Bucharest, 011061 Bucharest, Romania
- Academy of Romanian Scientists, Ilfov No. 3, 050044 Bucharest, Romania
| | - Mircea Beuran
- Department of Surgery, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari, Sector 5, 050474 Bucharest, Romania; (A.N.); (B.S.G.); (M.B.)
- Emergency Hospital Floreasca Bucharest, 8 Calea Floresca, Sector 1, 014461 Bucharest, Romania
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Siddiqui A, Lyons NB, Anwoju O, Cohen BL, Ramsey WA, O'Neil CF, Ali Z, Liang MK. Mesh Type With Ventral Hernia Repair: A Systematic Review and Meta-analysis of Randomized Trials. J Surg Res 2023; 291:603-610. [PMID: 37542774 DOI: 10.1016/j.jss.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Synthetic mesh is widely utilized for clean ventral hernia repair; however, it is unclear if synthetic mesh provides the same benefits with high-risk patients or during contaminated cases. Many surgeons use biologic mesh in these settings, but there is little evidence to support this practice. Our objective was to compare the clinical outcomes of utilizing biologic mesh versus synthetic mesh during ventral hernia repair. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a review of the literature was conducted using Cochrane library, EMBASE, Clinicaltrials.gov, and PubMed for randomized controlled trials published that compared biologic versus synthetic mesh during ventral hernia repair. The primary outcome was major complications defined as deep or organ space surgical site infection, reoperations, and hernia recurrences. RESULTS Of 1889 manuscripts screened, four publications were included. The four studies included a total of 758 patients, with 381 receiving biologic mesh and 377 receiving synthetic mesh. Compared to biologic mesh, synthetic mesh had lower rates of major complications (38.6% versus 23.4, risk ratio = 0.55, 95% confidence interval = 0.35 to 0.86, P = 0.009) and hernia recurrence (24.5 % versus 10.3%, risk ratio = 0.44, 95% confidence interval = 0.28 to 0.69, P = 0.004). In addition, there was a lower percentage of surgical site infection and reoperation in the synthetic mesh group. CONCLUSIONS Contrary to current surgical teaching, placement of permanent synthetic mesh into a contaminated field yielded rates of complications that were comparable or reduced compared to biologic mesh.
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Affiliation(s)
- Ali Siddiqui
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
| | - Nicole B Lyons
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.
| | - Oluwatunmininu Anwoju
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
| | - Brianna L Cohen
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Walter A Ramsey
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Christopher F O'Neil
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Zuhair Ali
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
| | - Mike K Liang
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
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Ellis R, Miller BT. Mesh Selection in Abdominal Wall Reconstruction: An Update on Biomaterials. Surg Clin North Am 2023; 103:1019-1028. [PMID: 37709387 DOI: 10.1016/j.suc.2023.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
A wide array of mesh choices is available for abdominal wall reconstruction, making mesh selection confusing. Understanding mesh properties can make mesh choice simpler. Each mesh has characteristics that determine its durability, ability to clear an infection, and optimal position of placement in the abdominal wall. For clean retromuscular hernia repairs, we prefer bare, heavy weight, permanent synthetic mesh. For contaminated retromuscular abdominal wall reconstruction cases, such as parastomal hernia repairs, we typically use bare, medium weight, permanent synthetic mesh. Biologic and biosynthetic meshes also have acceptable wound event and hernia recurrence rates when used in contaminated cases.
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Affiliation(s)
- Ryan Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Benjamin T Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Rendell VR, Pauli EM. Parastomal Hernia Repair. Surg Clin North Am 2023; 103:993-1010. [PMID: 37709401 DOI: 10.1016/j.suc.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Parastomal hernias (PHs) are common and contribute to significant patient morbidity. Despite 45 years of evolution, mesh-based PH repairs continue to be challenging to perform and remain associated with high rates of postoperative complications and recurrences. In this article, the authors summarize the critical factors to consider when evaluating a patient for PH repair. The authors provide an overview of the current techniques for repair, including both open and minimally invasive approaches. The authors detail the mesh-based repair options and review the evidence for choice of mesh to use for repair.
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Affiliation(s)
- Victoria R Rendell
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
| | - Eric M Pauli
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA.
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Hernandez A, Petersen R. Laparoscopic Ventral Hernia Repair. Surg Clin North Am 2023; 103:947-960. [PMID: 37709398 DOI: 10.1016/j.suc.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
The laparoscopic approach to ventral hernia repair is a safe and effective approach for both elective and emergent repair. The preoperative technical considerations include assessment of incarceration and potential for extensive adhesiolysis, size of defect, and atypical hernia locations. Preoperative considerations include weight loss and lifestyle modification. There are multiple methods of fascial defect closure and mesh fixation that the surgeon may consider via a laparoscopic approach, making it adaptable to varying clinical scenarios and anatomic challenges. Compared with open repair laparoscopic repair is associated with reduced surgical wound site infection, and compared with robotic repair outcomes are similar.
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Affiliation(s)
- Alexandra Hernandez
- Department of Surgery, Division of General Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356410, Seattle, WA 98195, USA
| | - Rebecca Petersen
- Department of Surgery, Division of General Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356410, Seattle, WA 98195, USA.
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Shi H, Wang R, Dong W, Yang D, Song H, Gu Y. Synthetic Versus Biological Mesh in Ventral Hernia Repair and Abdominal Wall Reconstruction: A Systematic Review and Recommendations from Evidence-Based Medicine. World J Surg 2023; 47:2416-2424. [PMID: 37268782 DOI: 10.1007/s00268-023-07067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/04/2023]
Abstract
AIM To compare the efficacy and safety of synthetic and biological meshes in ventral hernia repair (VHR) and abdominal wall reconstruction (AWR). METHODS We screened all clinical trials that reported the application of synthetic and biological meshes in VHR and AWR using Medline, Web of Science, and Embase (Ovid). Only comparative studies with similar baselines such as age, sex, body mass index, degree of wound contamination, and hernia defects between the intervention and control groups were included. Effect sizes with 95% confidence were pooled using a random- or fixed-effects model based on the size of heterogeneity. A sensitivity analysis was performed to test the stability of the results. RESULTS Ten studies with 1305 participants were included. Biological meshes were associated with significantly higher recurrence rate (OR, 2.09; 95% CI 1.42-3.08; I2 = 50%), surgical site infection (OR, 1.47; 95% CI 1.10-1.97; I2 = 30%), higher re-admission rate (OR, 1.51; 95% CI 1.05-2.17; I2 = 50%), and longer length of hospital stay (SMD, 0.37; 95% CI 0.10-0.65; I2 = 72%). Similar surgical site occurrence, re-operation rate, and mesh explantation rate were observed among biological and synthetic meshes. Biological meshes have no difference in recurrence rate as compared to synthetic meshes, between the clean-contaminated, and contamination-infected fields (OR, 1.41; 95% CI 0.41-4.87 vs 3.00; 95% CI 1.07-8.46; P = 0.36). CONCLUSION Synthetic meshes are a safe alternative to biological meshes for VHR and AWR. Considering the high cost of biological meshes, synthetic meshes are more appropriate for the VHR and AWR.
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Affiliation(s)
- Hekai Shi
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Rui Wang
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Wenpei Dong
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Dongchao Yang
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Heng Song
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Yan Gu
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China.
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Prabhu AS. Devices in Hernia Surgery. Surg Clin North Am 2023; 103:1011-1017. [PMID: 37709386 DOI: 10.1016/j.suc.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Despite the heavy reliance of surgeons on mesh with which to repair hernias, less attention is paid to the technical specifications of mesh and/or regulatory processes for bringing medical devices to market during surgical training. This article summarizes some of the key controversies and points regarding mesh materials and regulatory processes related to mesh devices.
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Affiliation(s)
- Ajita S Prabhu
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Crile A-100, Cleveland, OH 44195, USA.
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Alimi Y, Deldar R, Sosin M, Lofthus A, Nijhar K, Bartholomew AJ, Fan KL, Bhanot P. Outcomes of Immediate Multistaged Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence. Ann Plast Surg 2023; 91:473-478. [PMID: 37713152 DOI: 10.1097/sap.0000000000003641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection. METHODS We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma. RESULTS Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index (P = 0.006), bridge repair (P = 0.035), and postoperative surgical site infection (P = 0.005) were associated with hernia recurrence. CONCLUSION Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.
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Affiliation(s)
| | | | - Michael Sosin
- Plastic Surgery Arts of New Jersey, New Brunswick, NJ
| | | | | | | | - Kenneth L Fan
- Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
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36
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Schlosser KA, Warren JA. Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula. Surg Clin North Am 2023; 103:1029-1042. [PMID: 37709388 DOI: 10.1016/j.suc.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Surgery, Prisma Health, 701 Grove Road, Support Tower 3, Greenville, SC 29605, USA. https://twitter.com/KT_Schlosser
| | - Jeremy A Warren
- Department of Surgery, Division of Minimal Access Surgery, University of South Carolina School of Medicine Greenville, Prisma Health, 701 Grove Road, Support Tower 3, Greenville, SC 29605, USA.
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37
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Rodriguez-Quintero JH, Romero-Velez G, Mandujano C, Huang LC, Sreeramoju P, Malcher F. Slowly absorbable mesh in sublay ventral hernia repair in contaminated fields. Surg Endosc 2023; 37:8080-8090. [PMID: 37670192 DOI: 10.1007/s00464-023-10362-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/30/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND In the past years, there has been increasing evidence that supports the use of permanent mesh in contaminated wounds. Given this increased evidence, the indications to opt for slowly absorbable "biosynthetic" prostheses have been questioned. To address this, we compared the outcomes of slowly absorbable mesh in contaminated cases in a well-matched multicentric cohort. METHODS The Abdominal Core Health Quality Collaborative (ACHQC) database was queried for patients undergoing elective ventral hernia repair in Centers for Disease Control (CDC)-III operations (2013-2022). We compared demographics, hernia characteristics, and postoperative outcomes among types of mesh. We used propensity score matching to adjust for sex, diabetes, body mass index, smoking status, and operative time between mesh groups. Patients within other CDC classes and those with mesh positioned elsewhere than retro-rectus/preperitoneal space were excluded. RESULTS A total of 760 patients were included in the analysis. Slowly absorbable synthetic mesh (SA) was utilized in only 7% of the cases, while permanent (P) and biologic (B) mesh in 77% and 16%, respectively. After matching, 255 patients were studied. There was no difference in surgical site occurrence (8% SA, 16% P, 10% B, p = 0.27), surgical site infection (20% SA, 17% P, 12% B p = 0.54), surgical site occurrence requiring intervention (18% SA, 13% P, 14% B p = 0.72), readmission (12% SA, 14% P, 12% B, p = 0.90), or reoperation (8% SA, 2% P, 4% B, p = 0.14) at 30 days. In patients with 1-year follow-up, there was no difference in recurrence among groups (20% SA, 26% P, 24% B p = 0.90). CONCLUSION Based on our findings, SA has comparable outcomes to other types of mesh, particularly when an optimal retro-rectus repair is performed.
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Affiliation(s)
| | | | - Camilo Mandujano
- Department of Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Li-Ching Huang
- Center of Quantitative Sciences, Vanderbilt University, Nashville, TN, USA
| | | | - Flavio Malcher
- Department of Surgery, New York University, 530 1st Ave, New York, NY, USA.
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Roberts DJ, Leppäniemi A, Tolonen M, Mentula P, Björck M, Kirkpatrick AW, Sugrue M, Pereira BM, Petersson U, Coccolini F, Latifi R. The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review. BJS Open 2023; 7:zrad084. [PMID: 37882630 PMCID: PMC10601091 DOI: 10.1093/bjsopen/zrad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ari Leppäniemi
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Tolonen
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Andrew W Kirkpatrick
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, Calgary, Alberta, Canada
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Sugrue
- Department of Surgery Letterkenny, University Hospital Donegal, Donegal, Ireland
| | - Bruno M Pereira
- Department of Surgery, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, Rio de Janeiro, Brazil
- Department of Surgery, Campinas Holy House General Surgery Residency Program Director, Campinas, Sao Paulo, Brazil
| | - Ulf Petersson
- Department of Surgery, Skane University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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Jakob MO, Brüggemann A, Moser N, Candinas D, Beldi G, Haltmeier T. Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields. Surg Endosc 2023; 37:6885-6894. [PMID: 37311892 PMCID: PMC10462502 DOI: 10.1007/s00464-023-10144-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/16/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Prophylactic intra-abdominal onlay mesh (IPOM) implantation has been shown to reduce the rate of fascial dehiscence and incisional hernia. However, surgical site infection (SSI) in presence of an IPOM remains a concern. The aim of this study was to assess predictors for SSI following IPOM placement in hernia and non-hernia abdominal surgery in clean and contaminated surgical fields. METHODS Observational study including patients undergoing IPOM placement at a Swiss tertiary care hospital 2007-2016. IPOM implantation was performed in hernia and non-hernia elective and emergency abdominal surgery, including contaminated and infected surgical fields. The incidence of SSI was prospectively assessed by Swissnoso according to CDC criteria. The effect of disease- and procedure-related factors on SSI was assessed in multivariable regression analysis, adjusting for patient-related factors. RESULTS A total of 1072 IPOM implantations were performed. Laparoscopy was performed in 415 patients (38.7%), laparotomy in 657 patients (61.3%). SSI occurred in 172 patients (16.0%). Superficial, deep, and organ space SSI were found in 77 (7.2%), 26 (2.4%), and 69 (6.4%) patients, respectively. Multivariable analysis revealed emergency hospitalization (OR 1.787, p = 0.006), previous laparotomy (1.745, p = 0.029), duration of operation (OR 1.193, p < 0.001), laparotomy (OR 6.167, p < 0.001), bariatric (OR 4.641, p < 0.001), colorectal (OR 1.941, p = 0.001), and emergency (OR 2.510, p < 0.001) surgery, wound class ≥ 3 (OR 3.878, p < 0.001), and non-polypropylene mesh (OR 1.818, p = 0.003) as independent predictors for SSI. Hernia surgery was independently associated with a lower risk for SSI (OR 0.165, p < 0.001). CONCLUSION This study revealed emergency hospitalization, previous laparotomy, duration of operation, laparotomy, as well as bariatric, colorectal, and emergency surgery, abdominal contamination or infection, and usage of non-polypropylene mesh as independent predictors for SSI. In contrast, hernia surgery was associated with a lower risk for SSI. The knowledge of these predictors will help to balance benefits of IPOM implantation against the risk for SSI.
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Affiliation(s)
- Manuel O Jakob
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adriana Brüggemann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Moser
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Melland-Smith M, Miller B, Petro C, Beffa L, Prabhu A, Krpata D, LaBelle M, Tamer R, Rosen M. Single-staged retromuscular abdominal wall reconstruction with mesh at the time of ostomy reversal: are we crossing the line? An ACHQC Analysis. Surg Endosc 2023; 37:7051-7059. [PMID: 37353652 DOI: 10.1007/s00464-023-10176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 05/30/2023] [Indexed: 06/25/2023]
Abstract
INTRODUCTION The most appropriate method of reconstructing the abdominal wall at the site of a simultaneous stoma takedown is controversial. The contaminated field, concomitant GI procedure being performed and presence of a hernia all complicate decision-making. We sought to describe the surgical approaches, mesh type and outcomes of concomitant abdominal wall reconstruction during stoma takedown in a large hernia registry. METHODS AND PROCEDURES All patients who underwent stoma takedown with simultaneous hernia repair with retromuscular mesh placement from January 2014 to May 2022 were identified within the Abdominal Core Health Quality Collaborative (ACHQC). Patients were stratified by mesh type including permanent synthetic (PS), resorbable synthetic (RS) and biologic mesh. Association of mesh type with 30-day wound events and other complications and 1-year outcomes were evaluated. RESULTS There were 368 patients who met inclusion criteria. Eighty-nine patients had ileostomies, 276 colostomies and 3 had both. Two hundred and seventy-nine (75.8%) patients received PS mesh, 46 (12.5%) biologic, and 43 (11.7%) RS. Seventy percent (259/368) had a parastomal hernia, 75% (285/368) had a midline incisional hernia, and 48% (178/368) had both. All groups had similar preoperative comorbidities and the majority had a transversus abdominus release. All mesh groups had similar thirty-day SSI (13.2-14.3%), SSO (10.5-17.8%) and SSOPI (7.9-14.1%), p = 0.6. Three patients with PS mesh developed infected synthetic mesh and one PS mesh required excision. Four patients with PS developed an enterocutaneous fistula. Of these, only one patient was recorded as having both an enterocutaneous fistula and mesh infection. Thirty-day reoperation and readmission were similar across all mesh groups. Recurrence at 1-year was similar between mesh groups. Quality of life measured using HerQLes scores were higher at one year compared to baseline in all groups indicating improvement in hernia-specific quality of life. CONCLUSION Early complication rates associated with simultaneous stoma takedown and abdominal wall reconstruction are significant, regardless of mesh type utilized. Concomitant surgery should be weighed heavily and tailored to individual patients.
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Affiliation(s)
- Megan Melland-Smith
- Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, 9500 Euclid Ave, Crile Building, 10th Floor, Cleveland, OH, USA.
| | - Benjamin Miller
- Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, 9500 Euclid Ave, Crile Building, 10th Floor, Cleveland, OH, USA
| | - Clayton Petro
- Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, 9500 Euclid Ave, Crile Building, 10th Floor, Cleveland, OH, USA
| | - Lucas Beffa
- Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, 9500 Euclid Ave, Crile Building, 10th Floor, Cleveland, OH, USA
| | - Ajita Prabhu
- Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, 9500 Euclid Ave, Crile Building, 10th Floor, Cleveland, OH, USA
| | - David Krpata
- Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, 9500 Euclid Ave, Crile Building, 10th Floor, Cleveland, OH, USA
| | | | | | - Michael Rosen
- Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, 9500 Euclid Ave, Crile Building, 10th Floor, Cleveland, OH, USA
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Crepaz L, Sartori A, Podda M, Ortenzi M, Di Leo A, Stabilini C, Carlucci M, Olmi S. Minimally invasive approach to incisional hernia in elective and emergency surgery: a SICE (Italian Society of Endoscopic Surgery and new technologies) and ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) online survey. Updates Surg 2023; 75:1671-1680. [PMID: 37069372 DOI: 10.1007/s13304-023-01505-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/22/2023] [Indexed: 04/19/2023]
Abstract
Minimally invasive abdominal wall surgery is growing worldwide, with a constant and fast improvement of surgical techniques and surgeons' confidence in treating both primary and incisional hernias (IH). The Italian Society of Endoscopic Surgery and new technologies (SICE) and the ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) worked together to investigate state of the art in IH treatment in elective and emergency settings in Italy. An online open survey was designed, and Italian surgeons interested in abdominal wall surgery were invited to fill out a 20-point questionnaire on IH surgical procedures performed in their departments. Surgeons were asked to express their points of view on specific questions about technical and clinical variables in IH treatment. Preferred approach in elective IH surgery was minimally invasive (59.7%). Open surgery was the preferred approach in 40.3% of the responses. In emergency settings, open surgery was the preferred approach (65.4%); however, 34.5% of the involved surgeons declare to prefer the laparoscopic/endoscopic approach. Most respondents opted for conversion to open surgery in case of relevant surgical field contamination, with a non-mesh repair of abdominal wall defects. Among those that used the laparoscopic approach in the emergent setting, the majority (74%) used the size of the defect of 5 cm as a decisional cut-off. The spread of minimally invasive approaches to IH repair in emergency surgery in Italy is gaining relevance. Code-sharing through scientific societies can improve clinical practice in different departments and promote a tailored approach to IH surgery.
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Affiliation(s)
- Lorenzo Crepaz
- General and Mini-Invasive Surgery, San Camillo Hospital, Via Giovanelli 19, 38122, Trento, Italy.
| | - Alberto Sartori
- Department of General Surgery, Ospedale Di Montebelluna, Via Palmiro Togliatti, 16, 31044, Montebelluna, Treviso, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Monica Ortenzi
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121, Ancona, Italy
| | - Alberto Di Leo
- General and Mini-Invasive Surgery, San Camillo Hospital, Via Giovanelli 19, 38122, Trento, Italy
| | - Cesare Stabilini
- DISC (Department of Surgical Sciences), University of Genoa, Genoa, Italy
| | - Michele Carlucci
- General and Emergency Surgery, IRCCS San Raffaele Hospital, Milan, Italy
| | - Stefano Olmi
- Oncologic Surgery, Policlinico San Marco GSD, Zingonia (Bg), Corso Europa 7, 24040, Zingonia, Bg, Italy
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Ricker AB, Marturano MN, Matthews BD. What Mesh Should be Used in Hernia Repair? Adv Surg 2023; 57:225-231. [PMID: 37536855 DOI: 10.1016/j.yasu.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Ventral hernia repair is one of the most frequently performed general surgery operations in the world, yet the treatment of clean-contaminated and contaminated cases remains controversial. Biologic mesh has been thought to resist infection, decrease chronic wound complications, and reduce the need for reoperation. Their use continues to be predominant in contaminated and dirty cases. This article is a comprehensive review of what mesh to choose in both clean and contaminated single-staged, open ventral hernia repair with further considerations of tissue incorporation characteristics, cost, safety profiles, complications, recurrence, and long-term outcomes.
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Affiliation(s)
- Ansley Beth Ricker
- Department of Surgery at Atrium Health Carolinas Medical Center, 1000 Blythe Boulevard, Medical Education Building Ste 6A, Charlotte, NC 28203, USA. https://twitter.com/ansleybeth_14
| | - Matthew N Marturano
- Department of Surgery at Atrium Health Carolinas Medical Center, 1000 Blythe Boulevard, Medical Education Building Ste 6A, Charlotte, NC 28203, USA. https://twitter.com/MarturanoMd
| | - Brent D Matthews
- Department of Surgery at Atrium Health Carolinas Medical Center, 1000 Blythe Boulevard, Medical Education Building Ste 6A, Charlotte, NC 28203, USA.
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Ellis RC, Petro CC, Krpata DM, Beffa LRA, Miller BT, Montelione KC, Maskal SM, Tu C, Huang LC, Lau B, Fafaj A, Rosenblatt S, Rosen MJ, Prabhu AS. Transfascial Fixation vs No Fixation for Open Retromuscular Ventral Hernia Repairs: A Randomized Clinical Trial. JAMA Surg 2023; 158:789-795. [PMID: 37342018 PMCID: PMC10285673 DOI: 10.1001/jamasurg.2023.1786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/21/2023] [Indexed: 06/22/2023]
Abstract
Importance Transfascial (TF) mesh fixation in open retromuscular ventral hernia repair (RVHR) has been advocated to reduce hernia recurrence. However, TF sutures may cause increased pain, and, to date, the purported advantages have never been objectively measured. Objective To determine whether abandonment of TF mesh fixation would result in a noninferior hernia recurrence rate at 1 year compared with TF mesh fixation in open RVHR. Design, Setting, and Participants In this prospective, registry-based, double-blinded, noninferiority, parallel-group, randomized clinical trial, a total of 325 patients with a ventral hernia defect width of 20 cm or less with fascial closure were enrolled at a single center from November 29, 2019, to September 24, 2021. Follow-up was completed December 18, 2022. Interventions Eligible patients were randomized to mesh fixation with percutaneous TF sutures or no mesh fixation with sham incisions. Main Outcome and Measures The primary outcome was to determine whether no TF suture fixation was noninferior to TF suture fixation for open RVHR with regard to recurrence at 1 year. A 10% noninferior margin was set. The secondary outcomes were postoperative pain and quality of life. Results A total of 325 adults (185 women [56.9%]; median age, 59 [IQR, 50-67] years) with similar baseline characteristics were randomized; 269 patients (82.8%) were followed up at 1 year. Median hernia width was similar in the TF fixation and no fixation groups (15.0 [IQR, 12.0-17.0] cm for both). Hernia recurrence rates at 1 year were similar between the groups (TF fixation, 12 of 162 [7.4%]; no fixation, 15 of 163 [9.2%]; P = .70). Recurrence-adjusted risk difference was found to be -0.02 (95% CI, -0.07 to 0.04). There were no differences in immediate postoperative pain or quality of life. Conclusions and Relevance The absence of TF suture fixation was noninferior to TF suture fixation for open RVHR with synthetic mesh. Transfascial fixation for open RVRH can be safely abandoned in this population. Trial Registration ClinicalTrials.gov Identifier: NCT03938688.
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Affiliation(s)
- Ryan C. Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C. Petro
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lucas R. A. Beffa
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Benjamin T. Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Katie C. Montelione
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sara M. Maskal
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Braden Lau
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Aldo Fafaj
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven Rosenblatt
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J. Rosen
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S. Prabhu
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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Coelho R, Dhanani NH, Lyons NB, Bernardi K, Askenasy EP, Millas S, Holihan JL, Ali Z, Liang MK. Hernia Prevention Using Biologic Mesh and/or Small Bites: A Multispecialty 2 × 2 Factorial Randomized Controlled Trial. J Am Coll Surg 2023; 237:309-317. [PMID: 37458369 PMCID: PMC10574223 DOI: 10.1097/xcs.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Ventral incisional hernias are the most common complication after abdominal operation. Randomized trials have shown efficacy of prophylactic synthetic mesh and small bites. Adoption of these practices has been limited due to concerns with placement of synthetic mesh in contaminated cases and small bites in an overweight population. We sought to assess the efficacy of prophylactic biologic mesh and small bites to prevent postoperative major complications: ventral incisional hernias, surgical site infection, reoperation, and death. STUDY DESIGN High-risk patients (overweight/obese, current smoker) undergoing abdominal operation with a midline incision (5 cm or greater) were randomized (2 × 2 factorial trial) to receive either sublay biologic mesh or no mesh and either small bites (0.5 × 0. 5cm) or large bites (1 × 1 cm) fascial closure. The primary outcome measure was major complications at 1 year postoperative. CONSORT guidelines were followed, and this study was registered on clinicaltrials.gov (NCT03148496). Assuming α = 0.05, β = 0.20, and Δ = 20%, it was estimated that 105 patients were needed. Primary outcome was assessed using Fisher's exact test. RESULTS A total of 107 patients were randomized: 52 (49%) to mesh, 55 (51%) to no mesh, 55 (51%) to small bites, and 52 (49%) to large bites. Of the patients, 16% were smokers, 31% were overweight, and 55% were obese. At 1 year postoperative, there were no differences in major complications between groups (mesh vs no mesh 21% vs 16%, p = 0.62; small vs large bites 18% vs 19%, p = 1.00). CONCLUSIONS In this trial, biologic mesh and small bites appear to have no benefit. Further randomized trials are needed among high-risk patients before widespread adoption of prophylactic biologic mesh or small bites.
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Affiliation(s)
- Rainna Coelho
- From the Department of Surgery, University of Houston, Hospital Corporation of America Kingwood, Kingwood, TX (Coelho, Ali, Liang)
| | - Naila H Dhanani
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Nicole B Lyons
- Dewitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL (Lyons)
| | - Karla Bernardi
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Erik P Askenasy
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Stefanos Millas
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Zuhair Ali
- From the Department of Surgery, University of Houston, Hospital Corporation of America Kingwood, Kingwood, TX (Coelho, Ali, Liang)
| | - Mike K Liang
- From the Department of Surgery, University of Houston, Hospital Corporation of America Kingwood, Kingwood, TX (Coelho, Ali, Liang)
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Douissard J, Dupuis A, Ris F, Hagen ME, Toso C, Buchs NC. One-step totally robotic Hartmann reversal and complex abdominal wall reconstruction with bilateral posterior component separation: a technical note. Colorectal Dis 2023. [PMID: 37161645 DOI: 10.1111/codi.16583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 02/04/2023] [Accepted: 03/18/2023] [Indexed: 05/11/2023]
Abstract
AIM This paper describes a robotic approach to combined gastrointestinal continuity restoration and complex abdominal wall reconstruction after Hartmann's procedure complicated by large midline and parastomal hernias. METHODS A robotic Hartmann reversal is performed, followed by robotic retromuscular abdominal wall reconstruction of all ventral defects with bilateral posterior component separation using the double-docking approach. Surgical steps are thoroughly described, and the accompanying video highlights critical steps of the procedure, anatomical landmarks and technical details relevant to successful completion. RESULTS Complete restoration of the anatomy was achieved with an operative time of 6.5 h. Mobilization occured on day 1, and bowels were opened on day 3. Surgical discharge was possible on day 5. No intra-operative surgical complication occurred and follow-up at 6 months showed no recurrence or mid-term complication. CONCLUSION Combined minimally invasive reconstruction of the gastrointestinal tract and abdominal wall was feasible using a robotic system. In addition, potential advantages of postoperative rehabilitation and reduced surgical site complications are suggested. Prospective evaluation of the technique is ongoing.
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Affiliation(s)
- Jonathan Douissard
- Abdominal Surgery Division, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
| | - Arnaud Dupuis
- Abdominal Surgery Division, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
| | - Frederic Ris
- Abdominal Surgery Division, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
| | - Monika E Hagen
- Abdominal Surgery Division, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
| | - Christian Toso
- Abdominal Surgery Division, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
| | - Nicolas C Buchs
- Abdominal Surgery Division, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
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Mubashir M, Tang B, DeBernardo RL, Feng X. Surgical management of spontaneous bowel perforation and fascial dehiscence in a patient on bevacizumab and pembrolizumab in the setting of active Clostridium difficile infection. BMJ Case Rep 2023; 16:e253815. [PMID: 37137546 PMCID: PMC10163437 DOI: 10.1136/bcr-2022-253815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Immunotherapy such as bevacizumab and pembrolizumab is used to treat an increasing number of malignancies. These medications have been associated with poor wound healing and several gastrointestinal complications, including intestinal perforations in rare cases. We present a unique case of a patient with metastatic cervical cancer on pembrolizumab and recent bevacizumab therapy, presenting with a colonic perforation requiring urgent exploratory laparotomy, in the setting of active Clostridium difficile infection. She required a second laparotomy shortly after due to fascial dehiscence, where a synthetic absorbable mesh was used for fascial approximation. We review the factors that led to these events and describe the surgical technique used for safe abdominal closure.
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Affiliation(s)
| | - Brian Tang
- General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert L DeBernardo
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xiaoxi Feng
- General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Stephens I, Conroy J, Winter D, Simms C, Bucholc M, Sugrue M. Prophylactic onlay mesh placement techniques for optimal abdominal wall closure: randomized controlled trial in an ex vivo biomechanical model. Br J Surg 2023; 110:568-575. [PMID: 36918293 PMCID: PMC10683942 DOI: 10.1093/bjs/znad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/10/2022] [Accepted: 02/01/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Incisional hernias occur after up to 40 per cent of laparotomies. Recent RCTs have demonstrated the role of prophylactic mesh placement in reducing the risk of developing an incisional hernia. An onlay approach is relatively straightforward; however, a variety of techniques have been described for mesh fixation. The biomechanical properties have not been interrogated extensively to date. METHODS This ex vivo randomized controlled trial using porcine abdominal wall investigated the biomechanical properties of three techniques for prophylactic onlay mesh placement at laparotomy closure. A classical onlay, anchoring onlay, and novel bifid onlay approach were compared with small-bite primary closure. A biomechanical abdominal wall model and ball burst test were used to assess transverse stretch, bursting force, and loading characteristics. RESULTS Mesh placement took an additional 7-15 min compared with standard primary closure. All techniques performed similarly, with no clearly superior approach. The minimum burst force was 493 N, and the maximum 1053 N. The classical approach had the highest mean burst force (mean(s.d.) 853(152) N). Failure patterns fell into either suture-line or tissue failures. Classical and anchoring techniques provided a second line of defence in the event of primary suture failure, whereas the bifid method demonstrated a more compliant loading curve. All mesh approaches held up at extreme quasistatic loads. CONCLUSION Subtle differences in biomechanical properties highlight the strengths of each closure type and suggest possible uses. The failure mechanisms seen here support the known hypotheses for early fascial dehiscence. The influence of dynamic loading needs to be investigated further in future studies.
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Affiliation(s)
- Ian Stephens
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Jack Conroy
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
- Trinity Centre for Bioengineering, Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Des Winter
- Department of Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Ciaran Simms
- Trinity Centre for Bioengineering, Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Magda Bucholc
- EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Derry-Londonderry, UK
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
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Soback H, Lahav L, Franko R, Avital S. A three layered repair of a large perineal hernia: case report and review of the literature. Surg Case Rep 2023; 9:58. [PMID: 37043143 PMCID: PMC10097843 DOI: 10.1186/s40792-023-01636-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/30/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND A symptomatic perineal hernia is an uncommon complication after abdominoperineal resection (APR). Repairs of such hernias can be achieved by usage of autologous flaps, synthetic mesh, or biologic mesh, which reduce bowel adhesions. Studies have shown that prophylactic repair of the pelvic floor with biologic mesh during APR, can reduce the incidence of perineal hernia. CASE PRESENTATION A 71-year-old woman, after extended APR (eAPR) with primary closure of pelvic floor with absorbable mesh, presented to our outpatient clinic with a symptomatic, extensive perineal hernia. The patient underwent repair of the perineal hernia using a synthetic mesh and a bilateral gluteal flap procedure. In post operative care, signs of surgical site infection and a fluid collection demonstrated in a CT-scan, compelled a surgical drainage. A clear fluid negative for bacterial growth was drained and antibiotic treatment was initiated. After drainage, surgical site showed signs of significant improvement and patient was eventually discharged. CONCLUSION The rise in reported incidence of perineal hernia after eAPR coupled with the scarcity of data regarding the preferable repair technique suggests that there is a significant need for further prospective comparative studies.
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Affiliation(s)
- Hagai Soback
- Surgery B Department, Meir Medical Center, Tchernichovsky St. 59, Kfar Saba, Israel.
| | - Lauren Lahav
- Surgery B Department, Meir Medical Center, Tchernichovsky St. 59, Kfar Saba, Israel
| | - Rotem Franko
- Surgery B Department, Meir Medical Center, Tchernichovsky St. 59, Kfar Saba, Israel
| | - Shmuel Avital
- Surgery B Department, Meir Medical Center, Tchernichovsky St. 59, Kfar Saba, Israel
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Mazzola Poli de Figueiredo S, Tastaldi L, Mao RMD, Lima DL, Huang LC, Lu R. Biologic versus synthetic mesh in open ventral hernia repair: A systematic review and meta-analysis of randomized controlled trials. Surgery 2023; 173:1001-1007. [PMID: 36623959 DOI: 10.1016/j.surg.2022.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/28/2022] [Accepted: 12/11/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ventral hernia repair is one of the most common operations performed worldwide, and using mesh is standard of care to decrease recurrence. Biologic meshes are increasingly used to minimize complications associated with synthetic mesh, but with significantly higher cost and unclear efficacy. Until recently, most of the evidence supporting the use of biologic meshes was from retrospective cohorts with high heterogeneity and risk of bias. We aimed to report a meta-analysis of randomized controlled trials comparing the outcomes of synthetic and biologic mesh in elective open ventral hernia repair. METHODS A literature search of PubMed, Embase, and Cochrane Library databases was performed to identify randomized controlled trials comparing biologic and synthetic mesh in elective open ventral hernia repairs. The postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. RESULTS A total of 1,090 studies were screened, and 22 were fully reviewed. Four randomized controlled trials and 632 patients were included in the meta-analysis. Fifty-eight percent of patients had contaminated wounds (Wound Classification II-IV). Hernia recurrence (odds ratio 2.75; 95% confidence interval 1.76-4.31; P < .00001; I2 = 0%) and surgical site infections (odds ratio 1.53; 95% confidence interval 1.02-2.29; P = .04; I2 = 0%) were significantly more common in patients with biologic mesh. The rates of seroma, hematoma, and mesh removal were similar in both groups. CONCLUSION As compared to synthetic mesh, biologic meshes resulted in increased hernia recurrences and surgical site infections. Current evidence supports macroporous, uncoated synthetic mesh as the implant of choice for elective open ventral hernia repair, and its use should be considered even in contaminated cases.
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Affiliation(s)
| | - Luciano Tastaldi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX. https://twitter.com/LTastaldiMD
| | - Rui-Min Diana Mao
- Department of Surgery, University of Texas Medical Branch, Galveston, TX. https://twitter.com/DianaMaoMD
| | - Diego Laurentino Lima
- Department of Surgery, Montefiore Medical Center, Bronx, NY. https://twitter.com/DiLaurentino
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Richard Lu
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
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50
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Kibbe MR. JAMA Surgery-The Year in Review, 2022. JAMA Surg 2023; 158:441-442. [PMID: 36947068 DOI: 10.1001/jamasurg.2023.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Affiliation(s)
- Melina R Kibbe
- Editor, JAMA Surgery
- University of Virginia School of Medicine, Charlottesville
- UVA Health, Charlottesville, Virginia
- Department of Surgery, University of Virginia, Charlottesville
- Department of Biomedical Engineering, University of Virginia, Charlottesville
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