Repair of giant midline abdominal wall hernias: "components separation technique" versus prosthetic repair : interim analysis of a randomized controlled trial

Recent Advances in Functional Hydrogel for Repair of Abdominal Wall Defects: A Review

The abdominal wall plays a crucial role in safeguarding the internal organs of the body, serving as an essential protective barrier. Defects in the abdominal wall are common due to surgery, infection, or trauma. Complex defects have limited self-healing capacity and require external intervention. Traditional treatments have drawbacks, and biomaterials have not fully achieved the desired outcomes. Hydrogel has emerged as a promising strategy that is extensively studied and applied in promoting tissue regeneration by filling or repairing damaged tissue due to its unique properties. This review summarizes the five prominent properties and advances in using hydrogels to enhance the healing and repair of abdominal wall defects: (a) good biocompatibility with host tissues that reduces adverse reactions and immune responses while supporting cell adhesion migration proliferation; (b) tunable mechanical properties matching those of the abdominal wall that adapt to normal movement deformations while reducing tissue stress, thereby influencing regulating cell behavior tissue regeneration; (c) drug carriers continuously delivering drugs and bioactive molecules to sites optimizing healing processes enhancing tissue regeneration; (d) promotion of cell interactions by simulating hydrated extracellular matrix environments, providing physical support, space, and cues for cell migration, adhesion, and proliferation; (e) easy manipulation and application in surgical procedures, allowing precise placement and close adhesion to the defective abdominal wall, providing mechanical support. Additionally, the advances of hydrogels for repairing defects in the abdominal wall are also mentioned. Finally, an overview is provided on the current obstacles and constraints faced by hydrogels, along with potential prospects in the repair of abdominal wall defects.

Outcomes of Transversus Abdominis Release With Macroporous Polypropylene Mesh

INTRODUCTION

Transversus abdominis release (TAR) is increasingly being performed for reconstruction of complex incisional and recurrent ventral hernias, with complication rates ranging from 17.4% to 33.3% after open TAR (oTAR) or robotic TAR (rTAR). The purpose of this study was to describe the outcomes of patients undergoing TAR with macroporous polypropylene mesh (MPM) and to compare outcomes between oTAR and rTAR.

METHODS

A retrospective review of 183 consecutive patients undergoing TAR with MPM performed by a single surgeon at a single institution from 2015 to 2021 was performed. Patients with less than one year of follow-up were excluded. Univariate analysis was performed to compare outcomes between oTAR and rTAR patients.

RESULTS

Average patient age was 59.4 y, median body mass index was 33.2 kg/m2, and median hernia width was 12.0 cm. Forty 2 (23%) patients underwent oTAR, 127 (69%) underwent rTAR, and 14 (8%) underwent laparoscopic TAR. Patients experienced 16.4%, 10.4%, 3.8%, and 6.0% rates of overall complications, surgical site occurrences, surgical site infections, and other complications, respectively. At average follow-up of 2.3 y, a 2.7% hernia recurrence rate was observed. In comparison to patients undergoing oTAR, rTAR patients required shorter operative times and length of stay, and were less likely to experience postoperative complications overall, and other complications. Recurrence rates were similar between oTAR and rTAR.

CONCLUSIONS

Patients undergoing TAR with MPM experienced complication and recurrence rates in alignment with previously published results. In comparison to oTAR, rTAR was associated with more favorable perioperative outcomes and complication rates, but similar recurrence rates.

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

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.

The top 100 most-cited papers in incisional hernia: a bibliometric analysis from 2003 to 2023

PURPOSE

Incisional hernia (IH) is one of the most common complications after abdominal surgeries and may bring great suffering to patients. This study aims to evaluate the global trends in IH research from 2003 to 2023 and visualize the frontiers using bibliometric analysis.

METHODS

The literature search was conducted on the Web of Science for IH studies published from 2003 to 2023 and sorted by citation frequency. The top 100 most-cited articles were analyzed by the annual publication number, prolific countries and institutions, influential author and journal, and the number of citations through descriptive statistics and visualization.

RESULTS

The top paper was cited 1075 times and the median number of citations was 146. All studies were published between 2003 and 2019 and the most prolific year was 2003 with 14 articles. Jeekel J and Rosen M were regarded as the most productive authors with ten articles each and acquired 2738 and 2391 citations, respectively. The top three institutions with the most productive articles were Erasmus Mc, Carolinas Med Ctr, and Univ Utah, while the top three countries were the United States, Netherlands and Germany. The most frequent keyword was "incisional hernia" with 55 occurrences, followed by "mesh repair", "randomized controlled trial", and "polypropylene".

CONCLUSION

The 100 most-cited papers related to IH were published predominantly by USA and European countries, with randomized controlled trial (RCT) and observational study designs, addressing topics related to risk factors, complications, mesh repair, and mesh components.

Mesh Type With Ventral Hernia Repair: A Systematic Review and Meta-analysis of Randomized Trials

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.

Is there a role for botulinum toxin A in the emergency setting for delayed abdominal wall closure in the management of the open abdomen? A systematic review

INTRODUCTION

Emergency laparotomy for either trauma or non-trauma indications is common and management is varied. Use of the open abdomen technique allowing for planned re-look is an option; however, performing delayed definitive fascial closure (DFC) following this can be a challenge. The use of botulinum toxin-A (BTX) infiltration into the lateral abdominal wall has been well documented within the elective setting; its use within the emergency setting is undecided. This systematic review assesses the efficacy and safety of BTX injection into the lateral abdominal wall muscles in the emergency setting. The primary outcome is DFC rate.

METHODS

Systematic review was performed according to the PROSPERO registered protocol (CRD42020205130). Papers were dual screened for eligibility, and included if they met pre-stated criteria where the primary outcome was DFC. Articles reporting fewer than five cases were excluded. Bias was assessed using the Cochrane Risk of Bias and Joanna Brigg's appraisal tools.

FINDINGS

Fourteen studies were screened for eligibility, twelve full texts were reviewed and two studies were included. Both studies showed evidence of bias due to confounding factors and lack of reporting. Both studies suggested significantly higher rates of DFC than reported in the literature against standard technique (90.7% vs 66%); however, these data are difficult to interpret due to strict study inclusion criteria or lack of a control population.

CONCLUSION

The use of BTX is deemed safe and its effects in the emergency situation may have great potential. Unfortunately, to date, there is insufficient evidence to facilitate opinion.

Immediate Repair With a Self-Gripping Retromuscular Mesh for Abdominal Wall Defect Following Tumor Resection

Background: Prosthetic repair is always employed after large abdominal wall tumor resection, while chronic pain is one of the mesh-related complications after traumatic fixation. The objective of this research was to evaluate the outcomes of retromuscular repair with self-gripping mesh after abdominal wall tumor resection.Methods: The study was a monocentric retrospective analysis following STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statements of all patients with abdominal wall tumor >5 cm in diameter undergoing tumor excision and retromuscular repair with self-gripping mesh. Demographic, operative, early postoperative, and follow-up data were noted. Visual Analog Scale, ranging from 0 (no pain) to 10 (very severe pain), was used to estimate the wound pain.Results: 24 patients were included in this study, and the defect following tumor resection was 26.9±10.0 cm². There was no tumor recurrence or incisional hernia in median follow-up of 20 months, and the mean VAS score was 0.4. Three had foreign body feeling and no one suffered chronic pain.Conclusions: Immediate repair with a self-gripping retromuscular mesh can be considered as an effective way to treat an abdominal wall defect after resecting an abdominal wall tumor.

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.

Comparison of Surgical Treatment Results of Large Incisional Hernias

Introduction Incisional hernias are one of the most common complications after abdominal surgery. Surgical repairs of large incisional hernias have higher complications and recurrence rates compared to smaller incisional hernia repairs. For this reason, it is a more difficult and experience-requiring application for surgeons. In addition, there is no evidence-based consensus in the literature regarding the optimal surgical treatment of large incisional hernias. The aim of this study is to compare the results of the three most common surgical treatment methods used in a tertiary university hospital for the repair of large incisional hernias in terms of patients' characteristics, recurrence, and complication rates of the treatment methods. Methods Between 2014 and 2020, 366 patients with incisional hernias with facial defects larger than 10 cm in a tertiary medical faculty hospital located in eastern Turkey were analyzed. Patients were divided into three groups according to the surgical method used: open onlay prolene mesh (OPM) method, laparoscopic intraperitoneal sublay dual mesh (IPSDM) method, and open IPSDM method. Postoperative complications were divided into five groups as follows: wound complications, complications due to surgical procedures, medical complications, recurrences, and mortality. Treatment methods were compared according to the demographic characteristics of the patients and the postoperative complication rates. Results Of the patients, 141 were male and 225 were female, and the mean age was 58.0 ± 28 years. Of the patients, 81.9% were operated on with the open OPM, 10.9% with the laparoscopic IPSDM, and 7.1% with the open IPSDM. Wound complications occurred in 26.7% of patients, surgical complications in 3.2%, medical complications in 6.5%, recurrence in 9.2%, and mortality in 0.8% of patients. Total wound complications were significantly higher in the open OPM group (30%) (p = 0.009). Total surgery complications were significantly higher in the laparoscopic IPSDM group (15%) (p = 0.002). There was no significant difference between groups for medical complications (p = 0.540). Although no recurrence was observed in the open IPSDM group, no significant difference was observed between the groups (p = 0.099). There was no difference in mortality rates between the groups (p = 0.450). The overall complication rate was highest in the open OPM group (48.3%) and lowest in the open IPSDM group (27%) (p = 0.092). The operative time was found to be significantly shorter in open IPSDM (p < 0.001). The length of hospital stay was highest in the open OPM group and lowest in the open IPSDM group (p = 0.450). Conclusions Although hernia defect is greater in the open IPSDM compared to other methods, this method is more advantageous in terms of the complication rate associated with the surgical procedure, the overall complication rate, the duration of surgery, and the recurrence rate. Laparoscopic IPSDM is a more advantageous method in terms of the overall wound and medical complications.

Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization

Importance

Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations.

Objective

To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations.

Design, Setting, and Participants

This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021.

Main Outcomes and Measures

The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation.

Results

Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation.

Conclusions and Relevance

Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.

Open Anterior Component Separation for Complex Incisional and Ventral Hernias—When and How? Case Series Analysis

Closing the midline in patients with incisional hernias is the cornerstone for a functional reconstruction with low morbidity, low recurrence rates, and good cosmetic results, which is the ideal outcome for every hernia surgeon. However, in patients with large hernias (usually over 10 cm width) or in loss of domain cases, this goal is difficult to achieve. Anterior component separation with or without mesh reinforcement has been the procedure of choice for these patients despite its high rate of wound complications. The goal of our study is to evaluate the opportunity and necessity of the anterior component separation in patients with complex incisional or ventral hernias (defects larger than 10 cm, infected meshes). Data of patients with large incisional/ventral hernia operated using anterior component separation technique in the past 10 years were re-visited and analyzed from hospital records between January 2012 and December 2020. Demographic data (age, gender, body mass index, ASA score) and the main steps of the technique were recorded. Data were reported as mean and standard deviation. We used the anterior component separation in 66 cases, mainly for septic conditions (open abdomen, chronic and extended infections of the abdominal wall, chronic-infected meshes). For large parietal defects with aseptic local condition, we used mesh-reinforced anterior component separation (five patients). Mean age was 68.7 years. Among them, 29 patients developed wound complications (hematoma, seroma, infection). Mean hospital stay was 12.6 days. Recurrence was 18% in patients without mesh and zero in patients with mesh reinforcement after a minimum one-year follow-up. Anterior component separation is still a valid procedure in patients with large abdominal defects especially when a septic wound is to be closed. For large parietal defects, if a wide subcutaneous dissection is required, mesh-reinforced anterior component separation remains a valid alternative in abdominal wall reconstruction in certain cases (mainly aseptic conditions).

Xenogeneic Mesh Provides Safe and Durable Long-Term Outcomes in Abdominal Wall Reconstruction of High-Risk Centers for Disease Control and Prevention Class III and IV Defects

Objective

Evaluate long-term outcomes of abdominal wall reconstruction (AWR) using xenogeneic mesh in patients with Centers for Disease Control and Prevention (CDC) class III/IV defects. We hypothesized that AWR with xenogeneic mesh results in acceptable outcomes.

Background

Optimal mesh selection in AWR of CDC class III/IV defects is controversial. Outcomes using xenogeneic mesh are lacking.

Methods

We conducted a retrospective cohort study of patients who underwent AWR using xenogeneic mesh in CDC class III/IV defects from March 2005 to June 2019. Primary outcome was hernia recurrence (HR). Secondary outcomes were surgical site occurrence (SSO) and surgical site infection (SSI).

Results

Of consecutive 725 AWRs, we identified 101 patients who met study criteria. Sixty-eight patients had class III defects, while 33 had class IV defects. Patients had a mean age of 61.3 ± 11.1 years, mean body mass index of 31.8 ± 7.3 kg/m2, and mean follow-up time of 41.9 ± 26.3 months. Patients had HR rate of 21%, SSO rate of 49%, and SSI rate of 24. Class IV defects were predictive of SSOs (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.11-7.42; P = 0.029) but not HR (hazard ratio, 1.60; 95% CI, 0.59-4.34; P = 0.355) or SSIs (OR, 2.62; 95% CI, 0.85-8.10; P = 0.094).

Conclusions

Patients with class IV defects have a higher risk of SSOs, but not HR or SSIs, compared with patients with class III defects. Despite the high level of defect contamination, AWR with xenogeneic mesh demonstrated acceptable HR, SSO, and SSI rates. Therefore, safe and durable long-term outcomes are achievable in single-stage AWR using xenogeneic mesh for CDC class III/IV defects.

The combination of the three modifications of the component separation technique in the management of complex subcostal abdominal wall hernia

PURPOSE

The purpose of this study is to present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall hernia.

METHODS

Between January 2010 and January 2020, seven patients presenting at the high-volume academic center with complex subcostal hernia underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the "method of wide myofascial release" at the side of the hernia defect; (b) "open-book variation" of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position.

RESULTS

The median length and width of the complex subcostal hernias were 15 cm (10-19) and 15 cm (8-24), respectively. The overall morbidity rate was 57.1% (wound infection occurred in three patients, seroma in two patients, and skin necrosis in one patient). There was no hernia recurrence during the median follow-up period of 19 months.

CONCLUSION

The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall hernia.

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

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

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

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Trial Registration

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

Effect of Wound Contamination on Outcomes of Abdominal Wall Reconstruction Using Acellular Dermal Matrix: 14-Year Experience with More than 700 Patients

BACKGROUND

Patients with contaminated/dirty-infected defects are at high risk for postoperative complications after abdominal wall reconstruction (AWR). We evaluated outcomes of AWR using acellular dermal matrix (ADM) for mesh reinforcement and identified predictors of hernia recurrence (HR), surgical site occurrences (SSOs), and surgical site infections (SSIs).

STUDY DESIGN

We conducted a retrospective cohort study of patients who underwent AWR using ADM, from March 2005 to June 2019. Outcomes were compared between Centers for Disease Control and Prevention (CDC) wound classifications. The primary outcome measure was HR. Secondary outcomes were SSOs and SSIs.

RESULTS

We identified 725 AWRs using ADM that met the study criteria. Participants had a mean age of 60 ± 11.5 years, mean BMI of 31 ± 7 kg/m², and mean follow-up time of 42 ± 29 months. Three hundred two patients (41.6%) had clean defects, 322 patients (44.4%) had clean-contaminated defects, and 101 patients (13.9%) had contaminated/dirty-infected defects. Patients with contaminated/dirty-infected defects had an HR rate of 20.8%, SSO rate of 54.5%, and SSI rate of 23.8%. Multivariate logistic regression found that contaminated/dirty-infected defects were independent predictors of SSOs (OR 2.99; 95% CI 1.72-5.18; p < 0.0001) and SSIs (OR 2.32; 95% CI 1.27-4.25; p = 0.006), but not HR (OR 1.06; 95% CI 0.57-1.98; p = 0.859).

CONCLUSIONS

SSIs and SSOs increase as contamination levels rise, but the risk of HR does not. AWR with ADM provides safe and durable outcomes, even with increasing levels of contamination.

Large abdominal hernia repair with closed incision negative pressure therapy: a case series

OBJECTIVE

A major challenge of large abdominal incisional hernia repair is the high rates of wound complications. Closed incision negative pressure therapy (CINPT) can offer many treatment advantages in the management of these wounds and has been shown to reduce complications for other postoperative incisions. This study assesses the wound outcomes for hernia repair patients receiving CINPT.

METHOD

A six-year retrospective case series of patients who had undergone large abdominal incisional hernia repair wounds treated with CINPT was conducted. Outcomes for patients treated with CINPT were compared with patients who had not received CINPT acting as a control.

RESULTS

A total of 23 patients were treated with CINPT after hernia repair and compared with 12 patients in the control group. A statistically significant decreased rate of return to theatre (odds ratio: 0.12) was found in this study. Non-significant reductions in wound infection, seroma and wound dehiscence were also seen. No adverse events with CINPT therapy were reported.

CONCLUSIONS

CINPT, when used after large abdominal incisional hernia repair, may help in the prevention of wound complications.

Outcomes of mid-term and long-term degradable biosynthetic meshes in single-stage open complex abdominal wall reconstruction

OBJECTIVE

To assess clinical outcomes in patients that underwent open single-stage complex abdominal wall reconstruction (CAWR) with biosynthetic mesh.

METHODS

Retrospective observational study of two prospectively registered series of consecutive patients undergoing CAWR with either long-term degradable (LTD) Phasix^™ or mid-term degradable (MTD) BIO-A^® biosynthetic mesh in a single institution between June 2016 and December 2019.

RESULTS

From 169 patients with CAWR, 70 consecutive patients were identified who underwent CAWR with either LTD or MTD biosynthetic mesh. More than 85% of patients had an incisional hernia that could be classified as moderately complex to major complex due to a previous wound infection (67%), one or more complicating comorbidities (87.1%), one or more complicating hernia characteristics (75.7%) or contaminated or dirty defects (37.1%). Concomitant component separation was performed in 43 of 70 patients (61.4%). Overall surgical site infection (SSI) rate in these CAWR patients was 45.7%. Seventeen of 70 patients (24.3%) had computed tomography (CT) - and culture-confirmed SSI in direct contact of mesh, suspicious of mesh infection. Mesh removal for persistent local infection occurred in 10% (7 of 70) after a median of 229 days since surgery. Salvage rate of mesh after direct contact with infection was 58.8%. All removed meshes were in the LTD group. Seven patients (10%) had a recurrence; four patients in the LTD group (10%) had a recurrence at a median follow-up of 35 months and three patients in the MTD group (10%) at a median follow-up of 11 months. Three of the seven recurrences occurred in patients with SSI in persistent and direct contact with mesh.

CONCLUSIONS

Comorbid patients undergoing open complex abdominal wall reconstruction are at high risk of postoperative wound complications regardless of which type of biosynthetic mesh is used. When in persistent and direct contact with infection, long-term biodegradable biosynthetic meshes may need to be removed, whereas mid-term biodegradable biosynthetic meshes can be salvaged.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes

BACKGROUND

While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB).

METHODS

Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed.

RESULTS

A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m². Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05).

CONCLUSION

For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Bilateral transversus abdominis release: Complex hernia repair without sacrificing quality of life

BACKGROUND

Transversus Abdominis Release (TAR) during ventral hernia repair (VHR) allows for further lateral dissection by dividing the transversus abdominis muscles (TAM). The implications of division of the TAM on clinical and patient-reported outcomes has not be extensively studied.

METHODS

Adult patients undergoing retrorectus (RR) VHR with biosynthetic mesh with or without bilateral TAR were retrospectively identified. Post-operative and patient-reported outcomes (PROs) were collected.

RESULTS

Of 50 patients, 24 underwent TAR and 26 had RR repair alone. Median defect sizes were 449 cm² and 208 cm², respectively (p < 0.001). Rates of SSO and SSI were similar (p > 0.05). One TAR patient (4.2%) and four RR patients (15.4%) recurred (p = 0.26), with median follow up of 24 and 38 months. PROs improved significantly in both groups (p < 0.05).

CONCLUSION

Despite more complex abdominal wall reconstruction on larger defects, TAR has minimal major adverse events, low recurrence rates, and does not negatively affect PROs.

Long-term outcomes and quality of life assessment after posterior component separation with transversus abdominis muscle release (TAR)

BACKGROUND

Although transversus abdominis release (TAR) to treat large incisional hernias has shown favorable postoperative outcomes, devastating complications may occur when it is used in suboptimal conditions. We aimed to evaluate postoperative outcomes and long-term follow-up after TAR for large incisional hernias.

METHODS

A consecutive series of patients undergoing TAR for complex incisional hernias between 2014 and 2019 with a minimum of 6 month follow-up was included. Demographics, operative and postoperative variables were analyzed. Postoperative imaging (CT-scan) was also evaluated to detect occult recurrences. The HerQLes survey for quality of life (QoL) assessment was performed preoperatively and 6 months after the surgery.

RESULTS

A total of 50 TAR repairs were performed. Mean age was 65 (35-83) years, BMI was 28.5 ± 3.4 kg/m², and 8 (16%) patients had diabetes. Mean Tanaka index was 14.2 ± 8.5. Mean defect area was 420 (100-720) cm², average defect width was 19 ± 6.2 cm, and mesh area was 900 (500-1050) cm²; 78% were clean procedures, and in 60% a panniculectomy was associated. Operative time was 252 (162-438) minutes, and hospital stay was 4.5 (2-16) days. Thirty-day morbidity was 24% (12 patients), and 16% (8 patients) had surgical site infections. Overall recurrence rate was 4% (2 patients) after 28.2 ± 20.1 months of follow-up. QoL showed a significant improvement after surgery (p = 0.001).

CONCLUSIONS

The TAR technique is an effective treatment modality for large incisional hernias, showing an acceptable postoperative morbidity, a significant improvement in QoL, and low recurrence rates at long-term follow-up.

Synthetic versus Biologic Mesh for Complex Open Ventral Hernia Repair: A Pilot Randomized Controlled Trial

Background: Many surgeons utilize biologic mesh for elective complex ventral hernia repair (VHR; large hernias, contaminated fields, or patients with comorbid conditions). However, no randomized controlled trials (RCTs) have compared biologic and synthetic mesh. We hypothesize biologic mesh would result in fewer major complications at one-year post-operative compared with synthetic mesh. Patients and Methods: We performed a single-center, pilot RCT. All eligible patients undergoing complex, open VHR were randomly assigned to receive biologic or synthetic mesh placed in the retromuscular position. Primary outcome was major complications, namely, a composite of mesh infection, recurrence, or re-operation at one-year post-operative. Secondary outcomes included surgical site infections (SSI), seromas, hematomas, wound dehiscence, re-admissions, and Clavien-Dindo complication grade. Outcomes were assessed using Fisher exact test and Bayesian generalized linear models. Results: Of 87 patients, 44 were randomly assigned to biologic mesh and 43 to synthetic mesh. Most cases were wound class 2-4 (68%) and 75% had a hernia width >4 cm. Most patients were obese (70%) and had an American Society of Anesthesiogists (ASA) score of 3-4 (53%). Compared with patients in the synthetic mesh group, patients in the biologic mesh group had a higher percentage of: major complications at one-year post-operative (42.4% vs. 21.6%; relative risk [RR] = 1.96 [95% confidence interval {CI} = 0.94-4.08]; number needed to harm = 4.8; p = 0.071); SSI (15.9% vs. 9.3%; RR = 1.71 [95% CI = 0.54-5.42]; p = 0.362); wound dehiscence (25.0% vs. 14.0%; RR = 1.79 [95% CI = 0.73-4.41]; p = 0.205); and re-admissions (22.7% vs 9.3%; RR = 2.44 [95% CI = 0.83-7.20]; p = 0.105). Bayesian analysis demonstrated that compared with synthetic mesh, biologic mesh had a 95% probability of increased risk of major complications at one-year post-operative. No clear evidence of a difference was found on seromas, hematomas, or Clavien-Dindo complication grade. Conclusions: In elective complex open VHR, biologic mesh demonstrated no benefit compared with synthetic mesh in one-year outcomes. Moreover, Bayesian analysis suggests that biologic mesh may have an increased probability of major complications.

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

BACKGROUND

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

DATA SOURCES

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

CONCLUSIONS

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

Ultrasound-guided Hydro-dissection Facilitates Tissue Expander Placement and Components Separation in Complex Ventral Hernia Repair

Tissue expanders are known adjuncts in ventral hernia repair, used in a staged approach where tissue closure or coverage of the defect is preferred but inadequate. Placement of tissue expanders in the correct tissue plane can be difficult, especially in thin patients or with loss of domain. This case series describes a technique in which tissue expander placement is facilitated by ultrasound-guided hydro-dissection, following the placement of a transversus abdominis plane (TAP) block. In short, after induction of anesthesia, the same needle used for the ultrasound-guided TAP block can be repositioned by the anesthesiologist to instill tumescent solution into the fascial plane between the internal and external oblique muscles. This allows for identification of the fascial planes in the ensuing operation. Our technique may prove to be an alternative tool in the placement of tissue expanders for ventral hernia repair, or in other procedures requiring device placement.

The worst-case scenario: Bridging repair with a biologic mesh in high-risk patients with very large abdominal wall hernias-a prospective multicenter study

BACKGROUND

While modern techniques allow midline fascial closure for most abdominal hernias, a bridge repair with mesh may be the only alternative in very large defects. When the risk of infection is high, the use of prosthetic mesh is controversial. We aim to examine outcomes after bridge repair of very large abdominal hernias at high risk for postoperative infection with a second-generation biologic mesh.

METHODS

Prospective, multicenter, single-arm study of patients with very large abdominal hernias who received bridge repair with a neonatal bovine dermis mesh. Primary outcome was hernia recurrence, as identified on computed tomography 1 year after the operation. Secondary outcomes included mesh laxity, surgical site occurrences, and any other mesh-related complications. Independent risk factors of the outcomes were determined by univariate and multivariable analyses.

RESULTS

A total of 117 bridge repair patients were enrolled with a mean defect size of 442.5 ± 254.2 cm². The patients were predominantly obese (mean body mass index 36.5 ± 10.5) and with multiple comorbidities (Charlson comorbidity index 3 ± 2.5). Hernia recurrence was identified in 24 (20.5%) patients. An infected mesh at the index operation was an independent predictor of hernia recurrence, whereas obesity was an independent predictor of the pooled endpoint of recurrence and mesh laxity. Surgical site occurrences were recorded in 36.8% of the patients, and no independent risk factors were identified.

CONCLUSION

In patients with very large abdominal hernias and at high risk for postoperative infection, who cannot undergo midline fascial closure, a bridge repair with neonatal bovine dermis mesh offers an acceptable profile in terms of hernia recurrence and wound occurrences.

Application of double circular suturing technique (DCST) in repair of giant incision hernias

Background

Our study aims to explore the feasibility and safety of a double circular suturing technique (DCST) in the repair of giant incision hernias.

Methods

The clinical data of 221 patients (95 men and 126 women; the average age was 61.6 years) receiving DCST in the repair of giant incision hernia between January 2010 and December 2018 was analyzed retrospectively. One hundred and five primary and 16 recurrent patients underwent herniorrhaphy with anti-adhesion underlay mesh repair using DCST.

Results

All the 221 operations were performed successfully. The average preparation time before the operation and hospital stays were 3.7 days (range, 1-6 days) and 7.5 days (range, 2-16 days), respectively. The average diameter of the hernia ring defect observed intraoperatively was 16.4 cm (range, 12-22 cm). The average time of operation was 83.6 min (range, 43-195 min). There were 2 cases of intestinal fistula, 4 cases of wound infection, 2 cases of mesh infection, 7 cases of serum tumescence, 3 cases of pulmonary infection, and 2 cases of wound dehiscence occurred. One hundred and ninety-five patients were followed up for 6.7 years (range, 0.8-9.5 years) postoperatively. Of them, 9 patients recurred; 14 patients had chronic pain whose visual analog scale (VAS) was 2-4 cm (average 2.7 cm).

Conclusions

With limited preparation time before operations, few postoperative complications, and recurrence rate, DCST in the repair of giant incision hernia is safe and possible clinically.

Ventral incisional hernia case report: A therapeutic challenge

Incisional hernias are a very common condition and they still are considered to be a surgical challenge due to their recurrence rate. Smoking, obesity and age are risk factors for developing these abdominal wall defects. Despite recent advances in hernia repairs, the recurrence rates of hernias did not significantly diminished, even after the introduction of meshes. The aim of this article is to report a case of a ventral incisional hernia in a 37-year-old man and its successful treatment with a procedure known as the Alcino-Lázaro technique repair. This procedure has been shown to be very effective in incisional hernias, especially in obese patients. Furthermore, it is as cheap as it is reliable, since it can be performed without technological aid or expensive materials (mesh); thus, patients in low-income countries can greatly benefit from this procedure.

Application of double circular suturing technique (DCST) in the repair of large abdominal wall defects after resection of abdominal wall tumor

Background

The aim of this study was to investigate the clinical effects of repairing large defects using the double circular suturing technique (DCST) after resection of abdominal wall tumor.

Methods

The clinical data of 62 patients (25 men, 37 women; average age 41.7±22.4 years) who underwent DCST between October 2010 and November 2018 for the repair of large abdominal wall defects with anti-adhesion underlay mesh after resection of abdominal wall tumor were retrospectively analyzed. The maximum diameter of abdominal wall defect after resection of abdominal wall tumor was 10.4±5.6 cm. The course of disease was 1–341 months, and the average was 32.4 months. Operative time, postoperative hospitalization time, perioperative complications, tumor recurrence in situ, incidence of postoperative chronic pain, and hernia were recorded.

Results

All 62 operations were completed successfully. The operative time was 73.2±31.4 minutes, and the mean postoperative hospitalization time was 9.6 days (range, 2–20 days). In total, 54 patients were followed up postoperatively for a median 6.7 years (range, 0.9–9.0 years). Partial splitting of incisions occurred in 2 patients, fat liquefaction of incisions occurred in 3 patients, and chronic pain occurred in 4 patients. No tumor in situ recurrence, hernia, or other complications were found in any cases in the follow-up. Tumor metastasis occurred in 9 patients with 6 of these patients dying of tumour progression.

Conclusions

With simple operations, short procedure time, few complications, low tumor recurrence rate, and low incidence of postoperative chronic pain, application of DCST in the repair of large abdominal wall defects is effective after resection of abdominal wall tumor.

Combining anterior and posterior component separation for extreme cases of abdominal wall reconstruction

PURPOSE

The closure of midline in abdominal wall incisional hernias is an essential principle. In some exceptional circumstances, despite adequate component separation techniques, this midline closure cannot be achieved. This study aims to review the results of using both anterior and component separation in these exceptional cases.

METHODS

We reviewed our experience using the combination of both anterior and posterior component separation in the attempt to close the midline. Our first step was to perform a TAR and a complete extensive dissection of the retromuscular preperitoneal plane developed laterally as far as the posterior axillary line. When the closure of midline was not possible, an external oblique release was made. A retromuscular preperitoneal reinforcement was made with the combination of an absorbable mesh and a 50 × 50 polypropylene mesh.

RESULTS

Twelve patients underwent anterior and posterior component separation. The mean hernia width was 23.5 ± 5. The majority were classified as severe complex incisional hernia and had previous attempts of repair. After a mean follow-up of 27 months (range 8-45), no case of recurrence was registered. Only one patient (8.33%) presented with an asymptomatic bulging in the follow-up. European Hernia Society's quality of life scores showed a significant improvement at 2 years postoperatively in the three domains: pain (p = 0.01), restrictions (p = 0.04) and cosmetic (p = 0.01).

CONCLUSIONS

The combination of posterior and anterior component separation can effectively treat massive and challenging cases of abdominal wall reconstruction in which the primary midline closure is impossible to achieve despite appropriate optimization of surgery.

Quality of Life after Complex Abdominal Wall Reconstruction

Background

Component separation (CS) for tension-free approximation of fascial edges is the established technique for the repair of large ventral hernias mostly regarding midline defects. Recent studies suggest lower complication rates following a modified version of this technique using a partially endoscopic-assisted approach, whereas little is known about the quality of life (QoL) in the long-term evaluation of these patients.

Methods

A retrospective study and analysis of patients undergoing hernia repair using an open CS (OCS) and endoscopically assisted CS (ECS) technique, respectively, from 2011 to 2016 at the Rostock University Medical Center. Patients underwent a mesh-based sublay reinforcement following a distinct CS with closure of the linea alba. Patient characteristics, technical details, and short-term postoperative outcomes were determined by a physician chart review. A health-related QoL survey (EQ-5D) including a pain assessment was evaluated at a median of 19.5 months postoperatively.

Results

Thirty-five patients had a CS: 25 OCS and 10 ECS. Perioperative variables were comparable except for the median defect size (169 cm² OCS vs. 86 cm² ECS; p < 0.05) and maximum width of hernia (25 vs. 13 cm). Hospitalization lasted 16.6 days in the OCS group and 7.9 days in the endoscopic group (p = 0.04). Wound complications occurred in 24% of OCS and 10% of ECS patients.

Conclusions

Patients in the ECS group had a shorter hospital stay and less minor and major wound complications. These advantages led to a faster recovery directly affecting the QoL in the ECS group. This effect diminishes in the long-term follow-up with a positive trend towards the OCS technique.

Erratum: Addendum: Abdominal Wall Reconstruction: An Integrated Approach

[This corrects the article DOI: 10.1055/s-0038-1667062.].

Successful management of absent sternum in an infant using porcine acellular dermal matrix

Congenital absent sternum is a rare birth defect that requires early intervention for optimal long-term outcomes. Descriptions of the repair of absent sternum are limited to case reports, and no preferred method for management has been described. Herein, we describe the use of porcine acellular dermal matrix to reconstruct the sternum of an infant with sternal infection following attempted repair using synthetic mesh. The patient was a full-term male with trisomy 21, agenesis of corpus callosum, ventricular septal defect, patent ductus arteriosus, right-sided aortic arch, and congenital absence of sternum with no sternal bars. Following removal of the infected synthetic mesh, negative pressure wound therapy with instillation was used to manage the open wound and provide direct antibiotic therapy. When blood Creactive protein levels declined to ≤2 mg/L, the sternum was reconstructed using porcine acellular dermal matrix. At 21 months postoperative, the patient demonstrated no respiratory issues. Physical examination and computed tomography imaging identified good approximation of the clavicular heads and sternal cleft and forward curvature of the ribs. This case illustrates the benefits of negative pressure wound therapy and acellular dermal matrix for the reconstruction of absent sternum in the context of infected sternal surgical site previously repaired with synthetic mesh.

Pre-operative CT scan measurements for predicting complications in patients undergoing complex ventral hernia repair using the component separation technique

Background

The component separation technique (CST) is considered an excellent technique for complex ventral hernia repair. However, postoperative infectious complications and reherniation rates are significant. Risk factor analysis for postoperative complication and reherniation has focused mostly on patient history and co-morbidity and shows equivocal results. The use of abdominal morphometrics derived from CT scans to assist in risk assessment seems promising. The aim of this study is to determine the predictability of reherniation and surgical site infections (SSI) using pre-operative CT measurements.

Methods

Electronic patient records were searched for patients who underwent CST between 2000 and 2013 and had a pre-operative CT scan available. Visceral fat volume (VFV), subcutaneous fat volume (SFV), loss of domain (LOD), rectus thickness and width (RT, RW), abdominal volume, hernia sac volume, total fat volume (TFV), sagittal distance (SD) and waist circumference (WC) were measured or calculated. Relevant variables were entered in multivariate regression analysis to determine their effect on reherniation and SSI as separate outcomes.

Results

Sixty-five patients were included. VFV (p = 0.025, OR = 1.65) was a significant predictor regarding reherniation. Hernia sac volume (p = 0.020, OR = 2.10) and SFV per 1000 cm³ (p = 0.034, OR = 0.26) were significant predictors of SSI.

Conclusion

Visceral fat volume, subcutaneous fat volume and hernia sac volume derived from CT scan measurements may be used to predict reherniation and SSI in patients undergoing complex ventral hernia repair using CST. These findings may aid in optimizing patient-tailored preoperative risk assessment.

One-year outcome after repair of giant incisional hernia using synthetic mesh or full-thickness skin graft: a randomised controlled trial

Purpose

Repair of giant incisional hernia often requires complex surgery and the results of conventional methods using synthetic mesh as reinforcement are unsatisfactory, with high recurrence and complication rates. Our hypothesis was that full-thickness skin graft (FTSG) provides an alternative reinforcement material for giant incisional hernia repair and that outcome is improved. The aim of this study was to compare FTSG with conventional materials currently used as reinforcement in the repair of giant incisional hernia.

Methods

A prospective randomised controlled trial was conducted, comparing FTSG with synthetic mesh as reinforcement in the repair of giant (> 10 cm minimum width) incisional hernia. One-year follow-up included a blinded clinical examination by a surgeon and objective measurements of abdominal muscle strength using the Biodex-4 system.

Results

52 patients were enrolled in the study: 24 received FTSG and 28 synthetic mesh. Four recurrences (7.7%) were found at 1-year follow-up, two in each group. There were no significant differences regarding pain, patient satisfaction or aesthetic outcome between the groups. Strength in the abdominal wall was not generally improved in the study population and there was no significant difference between the groups.

Conclusion

The outcome of repair of giant incisional hernia using FTSG as reinforcement is comparable with repair using synthetic mesh. This suggests that FTSG may have a future place in giant incisional hernia repair.

Systematic review of transversus abdominis release in complex abdominal wall reconstruction

BACKGROUND

Transversus abdominis release (TAR), as a type of posterior component separation, is a new myofascial release technique in complex ventral hernia repair. TAR preserves rectus muscle innervation, creates an immense retromuscular plane and allows bilaminar ingrowth of the mesh. The place of the TAR within the range of established anterior component separation techniques (CST) is unclear. Aim of this systematic literature review is to estimate the position of the TAR in the scope of ventral hernia repair techniques.

METHODS

MEDLINE, Embase, Pubmed and the Cochrane controlled trials register and Science citation index were searched using the following terms: 'posterior component separation', 'transversus abdominis release', 'ventral hernia repair', 'complex abdominal wall reconstruction'. To prevent duplication bias, only studies with a unique cohort of patients who underwent transversus abdominis release for complex abdominal wall reconstruction were eligible. Postoperative complications and recurrences had to be registered adequately. The rate of surgical site occurrences and recurrences of the TAR were compared with those after anterior CST, published earlier in two meta-analyses.

RESULTS

Five articles met our strict inclusion criteria, describing 646 TAR patients. Methodological quality per study was good. Mean hernia surface was 509 cm² and 88% of the hernias were located in the midline. Preoperative risk stratification was distributed in low risk (10%), co-morbid (55%), potentially contaminated (32%) and infected (3%). Pooled calculations demonstrated a mean SSO rate of 15% after TAR (20-35% after anterior CST) and a mean 2-year hernia recurrence rate of 4% (13% after anterior CST). Mean hernia surface was 300 cm² in anterior component separation studies.

CONCLUSION

This review demonstrates that the transversus abdominis release is a good alternative for anterior CST in terms of SSO and recurrence, especially in very large midline ventral hernias.

Establishment of a Rabbit Model of Giant Abdominal Wall Hernia

PURPOSE

Animal models play an important role in abdominal wall hernia research. However, there is still no standard animal models for abdominal wall hernia. This study aimed to introduce a novel rabbit model of giant abdominal wall hernia.

METHODS

Sixteen 1-year-old New Zealand rabbits weighing 3 to 5 kg were used. After general anesthesia, a 5-cm longitudinal incision was made 2 cm lateral to the ventral midline, and a full-thickness laparotomy incision was made en bloc including the peritoneum (except skin). A full-thickness defect of the abdominal wall with a diameter of 3 cm was created. To increase the intraabdominal pressure, constipation was induced by deprivation of water perioperatively. The development of giant abdominal wall hernia was recorded. The bulge area of these rabbits was redissected to assess the hernia 3 months postoperatively.

RESULTS

Of the 16 rabbits, 13 (81.25%) rabbits had grade I healing and 3 (18.75%) rabbits had grade III healing. Reversible abdominal bulge at the incisional site was observed in all rabbits 3 to 18 days postoperatively. The average maximum diameter of the bulge was 8.73 ± 1.00 cm. Redissection of the bulge area showed successful establishment of giant abdominal wall hernia.

CONCLUSION

We successfully established a rabbit model of giant abdominal wall hernia, which may provide an easy-to-use tool for the research of abdominal wall hernia.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Open Intraperitoneal Onlay Mesh (IPOM) Technique for Incisional Hernia Repair

In an Expert Consensus Guided by Systematic Review the panel agreed that for open elective incisional hernia repair sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. Accordingly, the available literature on the open IPOM technique was searched and evaluated. Material and Methods: A systematic search of the available literature was performed in July 2018 using Medline, PubMed, and the Cochrane Library. Forty-five publications were identified as relevant for the key question. Results: Compared to laparoscopic IPOM, the open IPOM technique was associated with significantly higher postoperative complication rates and recurrence rates. For the open IPOM with a bridging situation the postoperative complication rate ranges between 3.3 and 72.0% with a mean value of 20.4% demonstrating high variance, as did the recurrence rate of between 0 and 61.0% with a mean value of 12.6%. Only on evaluation of the upward-deviating maximum values and registry data is a trend toward better outcomes for the sublay technique demonstrated. Through the use of a wide mesh overlap, avoidance of dissection in the abdominal wall and defect closure it appears possible to achieve better outcomes for the open IPOM technique. Conclusion: Compared to the laparoscopic technique, open IPOM is associated with significantly poorer outcomes. For the sublay technique the outcomes are quite similar and only tendentially worse. Further studies using an optimized open IPOM technique are urgently needed.

"Complex abdominal wall" management: evidence-based guidelines of the Italian Consensus Conference

To date, there is no shared consensus on a definition of a complex abdominal wall in elective surgery and in the emergency, on indications, technical details, complications, and follow-up. The purpose of the conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives: (1) to develop evidence-based recommendations to define “complex abdominal wall”; (2) indications in emergency and in elective cases; (3) management of “complex abdominal wall”; (4) techniques for temporary abdominal closure. The decompressive laparostomy should be considered in a case of abdominal compartment syndrome in patients with critical conditions or after the failure of a medical treatment or less invasive methods. In the second one, beyond different mechanism, patients with surgical emergency diseases might reach the same pathophysiological end point of trauma patients where a preventive “open abdomen” might be indicated (a temporary abdominal closure: in the case of a non-infected field, the Wittmann patch and the NPWT had the best outcome followed by meshes; in the case of an infected field, NPWT techniques seem to be the preferred). The second priority is to create optimal both general as local conditions for healing: the right antimicrobial management, feeding—preferably by the enteral route—and managing correctly the open abdomen wall. The use of a mesh appears to be—if and when possible—the gold standard. There is a lot of enthusiasm about biological meshes. But the actual evidence supports their use only in contaminated or potentially contaminated fields but above all, to reduce the higher rate of recurrences, the wall anatomy and function should be restored in the midline, with or without component separation technique. On the other site has not to be neglected that the use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination, seems to have a cost effective role too. The idea of this consensus conference was mainly to try to bring order in the so copious, but not always so “evident” literature utilizing and exchanging the expertise of different specialists.

Degenerative spondylolisthesis: a prospective cross-sectional cohort study on the role of weakened anterior abdominal musculature on causation

PURPOSE

Degenerative spondylolisthesis (DS) is a degenerative condition of the spine which, unlike others, is more common in a female population. Previous studies have highlighted possible causative factors such as facet tropism and pregnancy as reasons for this. This study sets out to assess the possible link between abdominal musculature and DS.

METHOD

A prospective cross-sectional cohort study in a single surgeon practice assessed all patients aged over 50 years attending for degenerative lumbar spinal complaints. Patient demographics, as well as the number of pregnancies, children, abdominal surgical procedures, were recorded.

RESULTS

We found 205 patients that met our inclusion criteria (98 Males/107 Females). Women with multiple pregnancies (p = 0.036) and abdominal surgeries (p = 0.021) were more likely to develop DS. Males with ventral hernias were more likely to have developed DS (p = 0.004).

CONCLUSION

This study highlights the important role that the abdominal musculature plays in stabilization of the spine and highlights its potential role as a factor in the development of DS. These slides can be retrieved under Electronic Supplementary Material.

Posterior Components Separation With Transversus Abdominis Release (TAR) Versus Alternative Techniques of Components Separation: Systematic Review

The aim of this study is to assess the clinical effectiveness of posterior abdominal wall components separation with transversus abdominis muscle release (PCS-TAR) in the management of ventral abdominal hernias. Ventral abdominal hernias complicate up to 11% of laparotomy wounds. Surgical management includes primary repair, hernioplasty, flaps, and components separation. A technique has been described to close large abdominal defects by releasing bilateral myofascial flaps of rectus abdominis from external oblique and advancing these flaps to the midline. Minimally invasive and endoscopic techniques were subsequently developed to reduce complications. A recently described method is PCS-TAR. The hypothesis is that PCS-TAR for abdominal wall reconstruction is associated with lower rates of wound complications and hernia recurrence than other components separation techniques. A comprehensive search of databases including Medline, Embase, Cochrane Central Register of Controlled Trials, and Scopus was conducted in accordance with PRISMA guidelines, looking for the primary outcomes of hernia recurrence and wound complications following different techniques of components separation. Inclusion and exclusion criteria were defined. The quality of studies was examined independently by 2 assessors. A total of 363 studies were identified. Three retrospective comparative studies met the inclusion criteria. No randomized control trial comparing different techniques of abdominal wall components separation was identified. No technique could be identified as superior to others, due to a paucity of the literature. However, based on a few retrospective cohort studies, PCS-TAR emerges as a well-tolerated new technique, with a low incidence of wound complications and hernia recurrence.

Nomenclature in Abdominal Wall Hernias: Is It Time for Consensus?

Abdominal wall reconstruction is a rapidly evolving area of surgical interest. Due to the increase in prevalence and size of ventral hernias and the high recurrence rates, the academic community has become motivated to find the best reconstruction techniques. Whilst interrogating the abdominal wall reconstruction literature, we discovered an inconsistency in hernia nomenclature that must be addressed. The terms used to describe the anatomical planes of mesh implantation ‘inlay’, ‘sublay’ and ‘underlay’ are misinterpreted throughout. We describe the misinterpretation of these terms and give evidence of where it exists in the literature. We give three critical arguments of why these misinterpretations hinder advances in abdominal wall reconstruction research. The correct definitions of the anatomical planes, and their respective terms, are described and illustrated. Clearly defined nomenclature is required as academic surgeons strive to improve abdominal wall reconstruction outcomes and lower complication rates.

Biological Implant for Complex Abdominal Wall Reconstruction: A Single Institution Experience and Review of Literature

AIM

To present our single institution and surgeon's complex abdominal wall reconstructions (CAWR) experience with Permacol™ mesh through a non-randomized study.

PATIENTS AND METHOD

Data of 51 consecutive patients were prospectively collected between 2003 and 2015. Patients had a median of 3 comorbidities (range 0-10) and 68% were Center for Disease Control class II-IV. The mean previous repair was 1.3 (range, 0-12), and 25 (44%) had a mesh in situ. The median defect size was 625 cm².

RESULTS

Among the 56 CAWR procedures, in 16 (29%) bowel resection/anastomosis was performed. The overall post-operative complication rate was 45%, and it was wound-related except from 1 patient dead for myocardial infarction. One was lost at follow-up. Five were re-operated for recurrence with a second Permacol mesh, leading to 14 (26%) overall recurrences at a mean follow-up of 44 months (range, 4-123). In 33 (59%) cases, fascial closure was achieved. The mesh placement was intraperitoneal in 89%, retro-muscular in 9% and supra-fascial in 1% of cases. A multivariate analysis showed that predictor risk for recurrence was more than 3 previous repairs, wound class III-IV, whereas age, type of comorbidities, defect size and fascial closure did not influence the recurrence. Median post-operative performance status was 0 (range; 0-3). A satisfaction questionnaire was obtained in 43 patients, and 86% of them were satisfied with the outcome.

CONCLUSIONS

Biological materials have the potential to reduce morbidity and improve outcome of definitive repair of CAWR.

Balancing mesh-related complications and benefits in primary ventral and incisional hernia surgery. A meta-analysis and trial sequential analysis

Background

Primary ventral hernia (PVH) and incisional hernia (IH) repair using a mesh appears to reduce hernia recurrence. However, are the benefits of mesh offset in part by mesh-related complications? The aim of this study was to compare placement of a mesh versus simple suture for recurrence and postoperative complications in the repair of PVH or IH.

Methods

Five databases were searched for randomized controlled trials (RCTs). The study population was patients with a PVH or IH undergoing hernia repair. Intervention was placement of a nonabsorbable synthetic mesh, regardless of mesh location, surgical technique, hernia characteristics or surgical setting compared to primary suture. Primary outcome was the incidence of hernia recurrence. Secondary outcomes were wound infection, hematoma, seroma, postsurgical pain, duration of operation, and quality of life. A random-effects meta-analysis with trial sequential analysis (TSA) was used.

Results

10 RCTs with a total of 1270 patients were included. A significant reduction of the incidence of PVH or IH recurrence using a mesh for repair (risk ratio [RR] 0.39, 95% CI 0.27–0.55; P < 0.00001; I² = 20%) was observed. TSA for recurrence, the accrued information size (1270) was 312% of the estimated required information size (RIS). Subgroup analysis for PVH and IH confirms reduction of recurrence after using a mesh in both groups. Overall postoperative complications did not show statistically significant differences between the mesh and surgical suture groups (RR 1.31, 95% CI 0.94–1.84; P = 0.12; I² = 27%) but the accrued information size was only 22.4% of RIS and by subgroups complications were only related with IH repair.

Conclusions

Evidence for the efficacy of repair of PVH or IH using a nonabsorbable synthetic mesh in terms of recurrence was found to be robust. Evidence for complications remains inconclusive.