Regeneration of abdominal wall aponeurosis: new dimension in Marlex peritoneal sandwich repair of incisional hernia

Hernia sac preservation in large incisional ventral hernia to prevent anterior component release

Large ventral hernias require complex surgical techniques, such as component separation. We are presenting a case of an incisional hernia measuring 15×8 cm. The hernia was covered with an overlying thin layer of skin and hernia sac. The skin of this layer was densely adherent to the underlying hernial sac. Because of the thin hernial sac and adherent nature of the skin, approximately 3 cm of the hernial sac was preserved. We used this hernial sac as the anterior sheath 'extension' for a tension-free closure. Posterior component separation with transverse abdominis muscle release was done to close the posterior layer without tension and to place a 23×16 cm mesh in the retrorectus plane. By using the hernial sac in repair, we avoided anterior component separation and achieved tension-free closure of the anterior layer.

'Flip-flap' hernia sac sandwich mesh hernioplasty for giant incisional hernia

Purpose: The treatment of giant ventral hernia (GVH) with domain loss is a challenge for surgeons. This modified and simplified form of sandwich technique in a form of flip-flap repair was done to assess the outcomes of GVH repair by using the hernia sac taking into account the late complications in terms of recurrence, mesh explantation and early: SSO (surgical site occurrence). Material and method: A total of 21 patients of GVH were treated with flip-flap repair technique in the department of surgery in a teaching hospital in the central India between December 16 to June 21. In flip-flap technique the hernia sac is tailored in the best possible way, by making multiple layered flaps encasing the Polypropylene mesh in between, separating it from intraperitoneal contents and subcutaneous tissue. Results: In this prospective and interventional study, the collected data revealed the mean follow up period of 22.3 months (7months to 48months). Mean age was 44.2years (27-65 years). SSO was seen in 38% of cases mainly in the form of SSI. No explantation of mesh and recurrence was seen in any patient. Conclusion: The flip-flap repair technique is safe and effective surgical technique that can be used for the treatment of GVH regardless of the size, BMI or position of hernia.

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

Background

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

Methods

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

Results

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

Conclusion

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

Tracking stem cells in the incisional hernial sac: a gaze beyond pure tissue repairs

OBJECTIVE

the hernial sac is typically a bilayer structure consisting of connective tissue lined underneath by peritoneum. Some incidental findings on it, like smooth muscle cells and heterotopic ossification, can be explained as the end-stage metaplasia from undifferentiated cells. This study aimed to search for mesenchymal stem cells in the incisional hernial sac by an immuno-histochemistry screening test.

METHODS

fifteen specimens of them were submitted to histochemistry analysis using CD133 monoclonal antibodies, a specific marker of mesenchymal stem cells. The biopsies were obtained from patients submitted to pure tissue repair for incisional hernias - the transposition with the hernial sac technique (Lázaro da Silva, 1971).

RESULTS

two-thirds of the specimens expressed on average 20 (twenty) CD133+ cells in each one.

CONCLUSION

despite the screening nature of this study, the hernial sac may be considered a source of stem cells. This could explain those abnormal findings, and perhaps the induction of new fibroblasts in procedures that use it to optimize wound healing.

Peritoneal flap hernioplasty for reconstruction of transverse incisional hernias

BACKGROUND

Repair of transverse incisional hernias is a surgical challenge with current methods of abdominal wall reconstruction. The peritoneal flap hernioplasty addresses this problem using flaps of hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. The operative technique and long-term results of 80 consecutive cases with transverse incisional hernias undergoing repair with this method are reported.

METHODS

Patients undergoing elective peritoneal flap hernioplasty repair for transverse incisional hernias from Jan. 1, 2010 to Dec. 31, 2014 were identified from the Lothian Surgical Audit system, a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in May 2019 from hospital records and telephone interview.

RESULTS

80 patients, (n = 53 male, 66%) were identified. Mean follow-up was 83 months (range 55-114 months) and mean postoperative stay was 6.4 days (range 1-23 days). Eleven repairs (14%) were for recurrent hernia. Mean mesh size applied (Optilene Elastic, 48 g/m², BBraun) was 747 cm² (ranged 150-1500 cm²). Redundant skin excision was performed in 54% of cases. Altogether, seven patients (8.8%) presented with postoperative complications: five superficial wound infections (6.3%), one symptomatic seroma (1.3%) and one recurrence (1.3%) within the follow-up period.

CONCLUSION

The peritoneal flap hernioplasty is associated with few complications and a very low recurrence rate. We propose this technique as the method of choice for reconstruction of transverse abdominal incisional hernias when primary fascial apposition is not possible.

Analysis of adhesions resulted from mesh fixation with fibrin sealant and suture: experimental intraperitoneal model

OBJECTIVE

To compare surgical fixation of polypropylene mesh (PP) and coated polypropylene mesh (PCD) using polypropylene suture and fibrin glue, as for the formation of intraperitoneal adhesions.

METHODS

A sample of 46 female Wistar rats were randomized into six groups: two control groups, with five rats each, were subjected to one medial incision (MI) and the other to a U-shaped incision (UI), none of these groups received the mesh. Two groups of PP mesh, with ten rats, fixed with suture (PPF), the other with six rats, fixed with biological glue (PPC). And two groups of PCD mesh, at first, with ten animals, the mesh was fixed with sutures (PCDFs) and the second with ten animals with biological glue (PCDC).

RESULTS

After 21 days, the control groups showed no significant adhesions. The PPC group showed a lower degree of adhesion than the PPF group (p = 0.01). There was no difference between the groups with PCD.

CONCLUSION

Comparison of fixation was statistically different only with PP mesh, with lesser degrees of adherence when using the glue. Adhesions were predominantly located at the extremities of the meshes studied.

Collagen foil (TissuFoil E) reduces the formation of adhesions when using polypropylene mesh for the repair of experimental abdominal wall defects

BACKGROUND AND AIMS

Polypropylene meshes (PPMs) are routinely used in the treatment of incisional hernias to achieve a tension-free closure of the abdominal wall. Severe adhesions are a common cause of intestinal obstruction, or even intestinal fistulas. Using a porcine model, we investigated whether applying a collagen foil (CF) to the undersurface of a PPM will reduce adhesion formation.

METHODS

In ten domestic pigs (20-25 kg), a median laparotomy was performed. In each animal the abdominal wall was reconstructed using three types of closure: simple closure by a running suture (control), PPM only, and PPM covered with CF (PPM-CF). After 6 weeks, the abdominal wall with adherent tissue was resected en bloc for macroscopic (quality and quantity of adhesion formation) and histological work-up.

RESULTS

The PPM-CF showed significantly less severe (1.9 vs 3.0 according to a scoring system), and also less extended (23.8 vs 55.9% total coverage of the mesh), adhesions to the resected abdominal wall. Histological examination revealed fewer and less severe inflammatory reactions, necrosis, and foreign body reactions for the mesh and CF (PPM-CF).

CONCLUSION

To combine meshes with the anti-adhesion properties of a CF may be another option to achieve more physiological and more tolerable prosthetic materials.

Incisional Hernioplasty with Extraperitoneal Onlay Polyester Mesh

Recurrent incisional hernia remains a major problem for the general surgeon. The high recurrence rate of incisional hernias after primary closure by tissue approximation led to the development of tension-free procedures using prosthetic materials. The goal of this study is to present the results of an extraperitoneal tension-free technique using a polyester mesh (Mersilene). A total of 43 patients with incisional hernias were surgically treated during a 9-year period in our department. Twenty-four patients (56%) had recurrent incisional hernias, 21 had primary repair by tissue approximation, and 3 had prolene mesh tension-free repair with wound infection. Patients’ mean age was 68.2 years, and the mean postoperative follow-up was 54.4 months. Immediate postoperative complications were noticed in 9 patients (21%) subcutaneous seroma in 6 (14%) and wound infection in 3 (7%). Recurrence was noticed in 4 patients (9%) during the first 9 postoperative months. Late minor complications such as restriction of abdominal wall motility and chronic pain was noticed in 3 (7%) patients. In conclusion, the extraperitoneal onlay tension-free incisional hernia repair using polyester mesh is an easy and safe procedure with no major morbidity or recurrence rate.

Neoorganogenesis and neohistogenesis by desired metaplasia of autogenous tissue stem cells in vivo: a critical and scientific evaluation with 125 years of review literature

Organogenesis and histogenesis during embryogenesis is well known. In the adult, it is minimal or absent in higher animals-mammals and humans. Neoformation of tissues and organs in vivo in dogs, monkey, and humans has been demonstrated using autogenous pluripotent stem cells. This is possible with the body's own potential, and the phenomena has been described as "desired metaplasia." The stem cells are surgically colonized with the tissues and/or tissue system where the tissue or organ is to be regenerated. Neoformation of abdominal wall aponeurosis, ureter, etc. has been possible by this technique. The technology has also been used in the management of human diseases like large incisional hernias and complex genitourinary or rectal fistulae. Because desired metaplasia is a new concept, the literature of the past 125 years has been scrutinized, selected articles on experimental colonization of tissues and cells have been analytically studied, and relevant articles have been critically analyzed with a new found concept of desired metaplasia and the proposed hypothesis of the first author based on embryologic principles. The literature reviewed revealed no article with the concept of desired metaplasia being responsible for neoorganogenesis and neohistogenesis. New organ and tissue formation is possible with the help of autogenous pluripotent stem cells if exposed to the proper environment and functional need, provided the tissues are embryologic neighbors. The phenomenon of desired metaplasia is discussed on a scientific basis.

Influence of implantation interval on the long-term biocompatibility of surgical mesh

BACKGROUND

The aim was to study the long-term tissue response to polypropylene mesh.

METHODS

This was a retrieval study that investigated 76 polypropylene meshes with a median implantation interval of 18 (range 2-180) months. Mesh was explanted following hernia recurrence, infection or pain. The median implantation interval was 20 (range 4-180) months in the recurrence group, 30 (range 5-48) months in the pain group and 10 (range 2-56) months in the infection group (P < 0.05, infection versus pain or recurrence). The inflammatory response was determined by immunohistochemistry of macrophages (CD68), polymorphonuclear granulocytes (CD15) and T and B lymphocytes (CD3 and CD20). The cell turnover within the interface mesh fibre-recipient tissue was measured by TUNEL for apoptosis or DNA strand breaks, Ki67 for cell proliferation and heat-shock protein (HSP) 70 for cell stress.

RESULTS

With the exception of HSP-70, levels of all variables decreased over time. Sex, age, type of previous operation or location of the mesh did not have a significant influence.

CONCLUSION

Long-term incorporated polypropylene mesh in humans has a more favourable tissue response with increasing implantation interval.

Tratamento cirúrgico das hérnias incisionais: experiência pessoal usando a malha de polipropileno monofilamentar-márlex

OBJETIVO: Relatar a experiência pessoal no tratamento cirúrgico de hérnias incisionais com a utilização da malha de polipropileno monofilamentar-márlex. MÉTODOS: Foram operados e seguidos 74 pacientes portadores de hérnia incisional originada de tratamento cirúrgico de diferentes afecções da cavidde abdominal, com idade entre 30 e 94 anos, sendo 39 do sexo feminino e 35 do sexo masculino. Destes 41,9% foram submetidos a hernioplastia incisional pela primeira vez e 58,1% já haviam tentado o tratamento sem sucesso. A técnica operatória usada foi a dissecção do saco herniário, ressecção da fibrose resultante de operações anteriores e fixação de tela de márlex substituindo ou reforçando a fáscia transversal por baixo dos músculos da parede abdominal. RESULTADO: 74 pacientes foram operados e seguidos de 1975 a 1995. Na última revisão, em maio de 1998, três pacientes haviam falecido, dois de doenças cardíacas e um de doença neoplasia. Apenas um paciente (1,3%) apresentou recidiva, no início da experiência. Este foi reoperado e terve sua hérnia incisional curada. CONCLUSÃO: o uso da tela de márlex tecnicamente aplicada é o método ideal para a cura definitiva das hérnias incisionais.