Prophylactic mesh placement in high-risk patients undergoing elective laparotomy: a systematic review

Botulinum toxin A in complex incisional hernia repair: a systematic review

PURPOSE

To evaluate the safety, efficacy, and short and long-term postoperative results of using BTA.

METHODS

We conducted a systematic review following the recommendations of the PRISMA method. We systematically reviewed the MEDLINE/PubMed and SCOPUS electronic databases for studies published between January 2010 and September 2021. This systematic review was registered in PROSPERO, with registration number CRD42021252445.

RESULTS

After applying the selection criteria, 11 relevant articles were selected. The total sample size was 1058 patients. Most studies aimed to assess the rate of fascial closure, followed by the rate of recurrence and reporting of postoperative complications, as well as the need for the components separation technique (CST). None of the studies reported serious complications from using BTA. Regarding fascial closure, all articles had rates above 75%, except for one. Surgical site events ranged between 19% and 29.4%. No recurrence in the group that used BTA was recorded in five studies. The other articles reported recurrence rates ranging from 6.4 to 11.4% in the groups that received BTA. The studies had varying follow-up times ranging from 1 to 49 months, with a mean of 18.6 months (± 11.2).

CONCLUSION

This review described most of the key points about the preoperative use of BTA in hernia repair. It can be concluded that the use of BTA is a safe and effective practice that promotes good short and long-term results. However, the limitations of the current literature prevent more accurate conclusions on the subject.

Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia

INTRODUCTION

Prophylactic meshes in high-risk patients prevent incisional hernias, although there are still some concerns about the best layer to place them in, the type of fixation, the mesh material, the significance of the level of contamination, and surgical complications. We aimed to provide answers to these questions and information about how the implanted material behaves based on its visibility under magnetic resonance imaging (MRI).

METHOD

This is a prospective multicentre observational cohort study. Preliminary results from the first 3 months are presented. We included general surgical patients who had at least two risk factors for developing an incisional hernia. Multivariate logistic regression was used. A polyvinylidene fluoride (PVDF) mesh loaded with iron particles was used in an onlay position. MRIs were performed 6 weeks after treatment.

RESULTS

Between July 2016 and June 2022, 185 patients were enrolled in the study. Surgery was emergent in 30.3% of cases, contaminated in 10.7% and dirty in 11.8%. A total of 5.6% of cases had postoperative wound infections, with the requirement of stoma being the only significant risk factor (OR = 7.59, p = 0.03). The formation of a seroma at 6 weeks detected by MRI, was associated with body mass index (OR = 1.13, p = 0.02).

CONCLUSIONS

The prophylactic use of onlay PVDF mesh in midline laparotomies in high-risk patients was safe and effective in the short term, regardless of the type of surgery or the level of contamination. MRI allowed us to detect asymptomatic seromas during the early process of integration.

STUDY REGISTRATION

 This protocol was registered at ClinicalTrials.gov (NCT03105895).

Risk factors associated to incisional hernia in stoma site after stoma closure: A systematic review and meta-analysis

BACKGROUND

This study aims to identify which risk factors are associated with the appearance of an incisional hernia in a stoma site after its closure. This in the sake of identifying which patients would benefit from a preventative intervention and thus start implementing a cost-effective protocol for prophylactic mesh placement in high-risk patients.

METHODS

A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. Studies reporting incidence, risk factors, and follow-up time for appearance of incisional hernia after stoma site closure were included. A fixed-effects and random effects models were used to calculate odds ratios' estimates and standardized mean values with their respective grouped 95% confidence interval. This to evaluate the association between possible risk factors and the appearance of incisional hernia after stoma site closure.

RESULTS

Seventeen studies totaling 2899 patients were included. Incidence proportion between included studies was of 16.76% (CI95% 12.82; 21.62). Out of the evaluated factors higher BMI (p = 0.0001), presence of parastomal hernia (p = 0.0023), colostomy (p = 0,001), and end stoma (p = 0.0405) were associated with the appearance of incisional hernia in stoma site after stoma closure, while malignant disease (p = 0.0084) and rectum anterior resection (p = 0.0011) were found to be protective factors.

CONCLUSIONS

Prophylactic mesh placement should be considered as an effective preventative intervention in high-risk patients (obese patients, patients with parastomal hernia, colostomy, and end stoma patients) with the goal of reducing incisional hernia rates in stoma site after closure while remaining cost-effective.

Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

INTRODUCTION

The incidence of incisional hernias (IH) after midline laparotomy varies from 11% to 20%. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is potentially prone to hernias because a Xiphoid to pubis laparotomy incision performed on patients who have undergone previous abdominal surgeries with the addition of chemotherapy and its related adverse effects.

METHODS

We performed a retrospective analysis on a prospectively maintained single institution database from March 2015 to July 2020. The inclusion criteria were patients who underwent CRS-HIPEC and had at least 6 months postoperative follow-up with post-operative cross-sectional imaging study.

RESULTS

Two hundred and one patients were included in the study. All patients underwent CRS-HIPEC with resection of previous scar and umbilectomy. Fifty-four patients were diagnosed with IH (26.9%). The major risk factors for IH in multivariate analysis were higher American society of Anesthesiologists score (ASA) (OR 3.9, P = 0.012), increasing age (OR 1.06, P = 0.004) and increasing BMI (OR 1.1, P = 0.006). Most of the hernia sites were median (n = 43, 79.6%). Eleven (20.4%) patients had lateral hernias due to stoma incisions or drain sites. Most of the median hernias were at the level of the resected umbilicus 58.9% (n = 23). Five (9.3%) of the patients with IH necessitated an urgent surgical repair.

CONCLUSION

We have demonstrated that more than a quarter of the patients after CRS-HIPEC suffer from IH and up to 10% of them may require surgical intervention. More research is needed to find the appropriate intraoperative interventions to minimize this sequela.

Evaluation of rectus abdominis muscle strength and width of hernia defect in patients undergoing incisional hernia surgery

BACKGROUND

The aim of this study was to analyze the strength status of the rectus abdominis muscle in patients with incisional hernia and the relationship between the width of the hernia defect and the strength of the rectus abdominis muscle.

METHODS

This is a observational cohort study of patients with medial line incisional hernia (July-October 2022), classified as W2 according to the European Hernia Society (EHS). The data collected were demographic and clinical characteristics related to hernia, and measure of the rectus abdominis muscle strength using an isokinetic dynamometer and a strain gauge. We analyzed the relationship between hernia width and rectus abdominis muscle strength with correlation tests to adjustment by age, sex, BMI, and body composition.

RESULTS

A total of 40 patients (64% female) with a mean age of 57.62 years (SD 11) were enrolled in the study. The mean BMI was 29.18 (SD 5.06), with a mean percentage of fat mass of 37.8% (SD 8.47) and a mean percentage of muscle mass of 60.33% (SD 6.43). The maximum width of the hernia defect was 6.59 cm (SD 1.54). In the male group, the mean bending force moment (ISOK_PT) was 94.01 Nw m (SD 34.58), bending force moment relative to body weight (ISOK_PT_Weight) was 103.32 Nw m (SD 37.48), and peak force (PK_90) was 184.71 N (SD 47.01). In the female group, these values were 58.11 Nw m (SD 29.41), 66.48 Nw m (SD 32.44), and 152.50 N (SD 48.49), respectively. Statistically significant differences were observed in the relationship between the data obtained with the isokinetic dynamometer and sex (p = 0.002), as well as between the data obtained with the isokinetic dynamometer and age (p = 0.006). Patients in the 90th percentile (P90) of rectus abdominis muscle strength also had smaller hernia defect widths (p = 0.048).

CONCLUSIONS

In this study, age and sex were identified as the most statistically significant predictor variables for rectus abdominis muscle strength. The width of the hernia defect exhibited a trend towards statistical significance.

Incisional Hernia Development after Live Donor Nephrectomy: Impact of Surgical Technique

BACKGROUND

Characteristics of incisional hernia (IH) formation after live donor nephrectomy (LDN) are not well-defined. The goal of this study was to describe the incidence of IH within 3 years after LDN and identify risk factors contributing to their formation.

METHODS

We performed a single-center, retrospective review of all LDN between February 2013 and October 2018. Patients with and without IH were compared based on donor and operative variables. Data were analyzed using chi-square tests with column proportions. Multivariable logistic regression with backward elimination was used to evaluate the likelihood of IH on the basis of potential risk factors.

RESULTS

Three hundred one individuals underwent live donor nephrectomy. Twenty-eight patients (9.3%) developed an IH, with a median time to development of 7 months (range: 2-24 months). Obesity (body mass index ≥30), periumbilical hand port, and vertical infraumbilical hand port were associated with increased risk of IH development on univariate analysis. On multivariate analysis, obesity and periumbilical hand port location were persistent risk factors for IH.

CONCLUSIONS

The incidence of IH after LDN is prevalent and associated with obesity and operative technique. Placing the hand port infraumbilical with a transverse fascial incision may reduce the risk of IH after LDN.

Pregnancy-associated desmoid fibromatosis: A Dutch multi-centre retrospective study

INTRODUCTION

The development of desmoid fibromatosis (DF) is associated with pregnancy. The current treatment consensus recommends active surveillance (AS). However, data in pregnancy-associated DF is scarce and it is uncertain whether AS is the best management strategy for this DF-subgroup. The aim of this study was to describe demographic, tumor, obstetric, treatment characteristics and treatment outcome in pregnancy-associated DF.

METHODS

Female DF patients who were 18-50 years old at time of diagnosis (2000-2020) and had a history (≤5 years) of pregnancy at time of diagnosis were included.

RESULTS

Overall, 62 patients were included. The most common locations were abdominal wall (74%), pelvis (10%) and extremities (10%). Mutational analysis was conducted in 31 patients of which 94% had CTNNB1-mutations. Ten patients (16%) were diagnosed during pregnancy, while the remainder were diagnosed after pregnancy with a median time from delivery to diagnosis of 19 months (1-60). The frontline management was AS in 38 patients (61%) of whom 12 (33%) developed progressive disease and surgery in 23 patients (37%). In total, 30 patients underwent surgery and five had local recurrence (17%). Positive resection margins were no prognostic factor. Nine patients received systemic treatment in second- or third-line.

CONCLUSIONS

Pregnancy-associated DF generally has an indolent behavior, where our results underscore the difficulty of establishing a clear definition of this entity. This study shows that AS should be the frontline management strategy for pregnancy-associated DF. When active treatment is indicated, surgery is a good option with low recurrence rates, even with positive (R1) resection margins.

The effect of prophylactic mesh implantation on the development of incisional hernias in patients with elevated BMI: a systematic review and meta-analysis

Background

Incisional hernia is a common complication after midline laparotomy. In certain risk profiles incidences can reach up to 70%. Large RCTs showed a positive effect of prophylactic mesh reinforcement (PMR) in high-risk populations.

Objectives

The aim was to evaluate the effect of prophylactic mesh reinforcement on incisional hernia reduction in obese patients after midline laparotomies.

Methods

Following the PRISMA guidelines, a systematic literature search in Medline, Web of Science and CENTRAL was conducted. RCTs investigating PMR in patients with a BMI ≥ 27 reporting incisional hernia as primary outcome were included. Study quality was assessed using the Cochrane risk-of-bias tool and certainty of evidence was rated according to the GRADE Working Group grading of evidence. A random-effects model was used for the meta-analysis. Secondary outcomes included postoperative complications.

Results

Out of 2298 articles found by a systematic literature search, five RCTs with 1136 patients were included. There was no significant difference in the incidence of incisional hernia when comparing PMR with primary suture (odds ratio (OR) 0.59, 95% CI 0.34–1.01, p = 0.06, GRADE: low). Meta-analyses of seroma formation (OR 1.62, 95% CI 0.72–3.65; p = 0.24, GRADE: low) and surgical site infections (OR 1.52, 95% CI 0.72–3.22, p = 0.28, GRADE: moderate) showed no significant differences as well as subgroup analyses for BMI ≥ 40 and length of stay.

Conclusions

We did not observe a significant reduction of the incidence of incisional hernia with prophylactic mesh reinforcement used in patients with elevated BMI. These results stand in contrast to the current recommendation for hernia prevention in obese patients.

PROPHYlactic Implantation of BIOlogic Mesh in peritonitis (PROPHYBIOM): a prospective multicentric randomized controlled trial

BACKGROUND

Patients undergoing emergency surgery for peritonitis are at increased risk of abdominal wall-related complications. In patients with peritonitis, the risk of incisional hernia (IH) is extremely elevated. The evaluation of quality of life of patients with incisional hernia showed lower mean scores on physical components of health-related quality of life and body image. Furthermore, the arise of a post-operative abdominal wall complication (i.e., wound dehiscence, evisceration and IH) greatly increases morbidity and mortality rates and prolongs the hospitalization.

METHODS

The present study aims to evaluate the efficacy of the use of a swine dermal collagen prosthesis implanted preperitoneally as a prophylactic procedure in urgency/emergency setting against abdominal wall complications in patients operated with contaminated/infected field in peritonitis. The sample size was defined in 90 patients divided in two arms (prosthesis positioning versus normal wall abdominal closure). The follow-up will be performed at 3, 6, and 12 months after surgery. The percentage of incisional hernias, wound infections, and adverse events will be investigated by physical examination and ultrasound.

DISCUSSION

The objective is to evaluate the possibility to reduce the incisional hernia rate in patients undergoing urgent/emergent laparotomy in contaminated/infected field with peritonitis by using swine dermal collagen prosthesis preperitoneal positioning as a prophylactic procedure.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04681326. Registered (retrospectively after first patient recruited) on 23 December 2020.

ONLAY VERSUS SUBLAY TECHNIQUES FOR INCISIONAL HERNIA REPAIR: 30-DAY POSTOPERATIVE OUTCOMES

ABSTRACT BACKGROUND: The development of an incisional hernia is a common complication following laparotomy. It also has an important economic impact on healthcare systems and social security budget. The mesh reinforcement of the abdominal wall was an important advancement to increase the success of the repairs and reduce its long-term recurrence. The two most common locations for mesh placement in ventral hernia repairs include the premuscular (onlay technique) and retromuscular planes (sublay technique). However, until now, there is no consensus in the literature about the ideal location of the mesh. AIM: The aim of this study was to compare the two most common incisional hernia repair techniques (onlay and sublay) with regard to the complication rate within the first 30 days of postoperative care. METHOD: This study analyzes 115 patients who underwent either onlay or sublay incisional hernia repairs and evaluates the 30-day postoperative surgical site occurrences and hernia recurrence for each technique. RESULTS: We found no difference in the results between the groups, except in seroma formation, which was higher in patients submitted to the sublay technique, probably due to the lower rate of drain placement in this group. CONCLUSION: Both techniques of mesh placement seem to be adequate in the repair of incisional hernias, with no major difference in surgical site occurrences.

Midline incisional hernia prophylaxis using synthetic mesh in an emergency or urgent gastrointestinal tract surgery: a protocol for multicentre randomised clinical trial

INTRODUCTION

Between 5% and 30% of abdominal incisions eventually result in incisional hernias (IHs) that can lead to severe complications and impaired quality of life. Unfortunately, IH repair is often unsuccessful; therefore, hernia prophylaxis is an important issue. The efficacy of mesh augmentation has been proven for hernia prophylaxis in high-risk patients, but no randomised clinical trial has evaluated prophylactic mesh placement in emergency/urgent gastrointestinal operations.

METHODS AND ANALYSIS

A multicentre, prospective randomised, open and patient-assessor blinded endpoint design will be conducted. A total of 470 patients will be enrolled and randomly allocated to retrorectus mesh augmentation with lightweight polypropylene mesh or primary suture closure. The primary outcome is IH occurrence within 24 months of follow-up, while other clinical outcomes are secondary endpoints. A cost-effectiveness analysis will be conducted from the societal and provider perspectives.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Ramathibodi Hospital (MURA2020/1478) and Vajira Hospital (COA164/2563). The protocol is on the process of submission to the local ethics committee of the other study sites. Results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

TCTR20200924002.

Incarcerated ventral wall hernia after robotic urogynecologic surgery: A case report

Trocar site hernia is a rare complication of minimally invasive surgery, with incidence estimates varying widely. Studies have demonstrated rates of up to 1.2% in patients undergoing gynecologic surgery. Yet, little is known about hernia risk in the urogynecologic patient population who undergo robotic reconstructive surgery. Risk factors for the development of trocar site hernia include both incisional risk factors (trocar placement location, trocar diameter, intraoperative trocar manipulation) and patient risk factors (obesity, pelvic organ prolapse or other hernia). This report presents a case of large incarcerated small bowel hernia at a trocar site following robotic urogynecologic surgery and the resulting interventions, including repeat surgery, to reduce the hernia. This case should prompt urogynecologic surgeons to check port sites after extensive dissections to assess if large peritoneal or fascial defects need additional closure.

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Complex robotic urogynecologic surgery may increase the risk of trocar site hernia.

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Pelvic organ prolapse is an important risk factor to consider for trocar site hernia.

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Surgeons should inspect robotic port sites for extensions after complex dissection.

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Careful closure of peritoneal and/or fascial extensions may be warranted.

Risk-benefit assessment of onlay and retrorectus mesh augmentation for incisional hernia prophylaxis: A secondary analysis from network meta-analysis

BACKGROUND

Mesh augmentation has proved efficacious for the prevention of incisional hernia (IH). A recent network meta-analysis (NMA) identified onlay and retrorectus mesh (OM and RM) as the most effective therapeutic options, but the risk of surgical site infection (SSI) and other complications require additional consideration.

METHODS

The NMA generated pooled risk differences (RD) for the benefits of reducing IH and the risk of SSI and composite seroma/hematoma (CSH) for use in Monte-Carlo data simulations with 1000 replications. Mean incremental risk-benefit ratios (IRBR), i.e., the ratio of incremental risk (or RD) and incremental benefit, and 95% confidence intervals (95% CI) were estimated with a probability of risk-benefits (PRB) across risk-benefit acceptability thresholds from the acceptability curves generated.

RESULTS

The RDs of IH were 0.237 and 0.201 lower in OM and RM than primary suture closure, compared to 0.027 and -0.001 for SSI. IRBRs (95% CI) for SSI risk were -0.118 (-0.124, -0.112) and 0.006 (-0.002, 0.013) for OM and RM, respectively. PRBs were much higher in RM than OM, especially at low acceptability thresholds of 0.05 and 0.1. IRBRs (95% CI) for CSH were -0.388 (-0.395, -0.381) and -0.105 (-0.111, -0.100) for OM and RM, respectively. RM yielded a PRB of 0.87 at an acceptability threshold of 0.2, in contrast to OM, which did not.

CONCLUSION

Overall, RM offered improved benefit in IH prophylaxis over the risk of complications relative to OM and appeared to be the preferred treatment option for this indication.

Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients

BACKGROUND

In recent decades, biologic mesh (BM) has become an important adjunct to surgical practice. Recent evidence-based clinical applications of BM include but are not limited to: reconstruction of abdominal wall defects; breast reconstruction; face, head and neck surgery; periodontal surgery; other hernia repairs (diaphragmatic, hiatal/paraesophageal, inguinal and perineal); hand surgery; and shoulder arthroplasty. Prior systematic reviews of BM in complex abdominal wall hernia repair had several shortcomings that our comprehensive review seeks to address, including exclusion of laparoscopic repair, assessment of risk of bias, use of an acceptable meta-analytic method and review of risk factors identified in multivariable regression analyses.

MATERIALS AND METHODS

We sought articles of BM for open ventral hernia repair reporting on early complications, late complications or recurrences and included minimum of 50. We used the quality in prognostic studies risk of bias assessment tool. Random effects meta-analysis was applied.

RESULTS

This comprehensive review selected 62 articles from 51 studies that included 6,079 patients. Meta-analytic pooling found that early complications are present in about 50%, surgical site occurrences (SSOs) in 37%, surgical site infections (SSIs) in 18%, reoperation in 7%, readmission in 20% and mortality in 3%. Meta-analytic estimates of late outcomes included overall complications (42%), SSOs (40%) and SSIs (22%). Specific SSOs included seroma (14%), hematoma (4%), abscess (10%), necrosis (5%), dehiscence (8%) and fistula formation (5%). Reoperation occurred in about 17%, mesh explantation in 9% and recurrence in 36%.

CONCLUSION

Estimates of nearly all outcomes from individual studies were highly heterogeneous and sensitivity analyses and meta-regressions generally failed to explain this heterogeneity. Recurrence is the only outcome for which there are consistent findings for risk factors. Bridge placement of BM is associated with higher risk of recurrence. Prior hernia repair, history of reintervention and history of mesh removal were also risk factors for increased recurrence.

Biomechanical and adhesion comparison of linea alba prophylactic reinforcement with coated and uncoated three-dimensional T-shaped mesh in rabbits

Purpose:

Incisional hernia (IH) is a frequent complication of median laparotomy. The use of prophylactic mesh to reduce IH incidence has gained increasing attention. We hypothesized that in an animal model, linea alba prophylactic reinforcement with a three-dimensional T-shaped polypropylene mesh results in greater abdominal wall resistance.

Methods:

Study was performed in 27 rabbits. After abdominal midline incision, animals were divided into three groups according to the laparotomy closure method used: (1)3D T-shaped coated mesh; (2)3D T-shaped uncoated mesh; and (3) closure without mesh. After 4 months, each animal’s abdominal wall was resected and tensiometric tests were applied. Results included IH occurrence, adhesions to the mesh, and wound complications.

Results:

There was no significant difference between the groups in maximum tensile strength (p=0.250) or abdominal wall elongation under maximum stress (p=0.839). One rabbit from the control group developed IH (p=1.00). Small intestine and colon adhesions occurred only in the uncoated mesh group (p<0.001) and the degree of adhesions was higher in this group compared to the coated mesh group (p<0.05).

Conclusion:

Use of the current 3D T-shaped prophylactic mesh model did not result in a significant difference in tensiometric measurements when compared with simple abdominal wall closure in rabbits.

A new three-step hybrid approach is a safe procedure for incisional hernia: early experiences with a single centre retrospective cohort

Purpose

In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh.

Objectives

To evaluate first perioperative outcomes with this technique.

Methods

From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤ 10 cm underwent a elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed.

Results

Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks.

Conclusion

A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.

Can Electric Nose Breath Analysis Identify Abdominal Wall Hernia Recurrence and Aortic Aneurysms? A Proof-of-Concept Study

Introduction. This pilot study evaluates if an electronic nose (eNose) can distinguish patients at risk for recurrent hernia formation and aortic aneurysm patients from healthy controls based on volatile organic compound analysis in exhaled air. Both hernia recurrence and aortic aneurysm are linked to impaired collagen metabolism. If patients at risk for hernia recurrence and aortic aneurysms can be identified in a reliable, low-cost, noninvasive manner, it would greatly enhance preventive options such as prophylactic mesh placement after abdominal surgery. Methods. From February to July 2017, a 3-armed proof-of-concept study was conducted at 3 hospitals including 3 groups of patients (recurrent ventral hernia, aortic aneurysm, and healthy controls). Patients were measured once at the outpatient clinic using an eNose with 3 metal-oxide sensors. A total of 64 patients (hernia, n = 29; aneurysm, n = 35) and 37 controls were included. Data were analyzed by an automated neural network, a type of self-learning software to distinguish patients from controls. Results. Receiver operating curves showed that the automated neural network was able to differentiate between recurrent hernia patients and controls (area under the curve 0.74, sensitivity 0.79, and specificity 0.65) as well as between aortic aneurysm patients and healthy controls (area under the curve 0.84, sensitivity 0.83, and specificity of 0.81). Conclusion. This pilot study shows that the eNose can distinguish patients at risk for recurrent hernia and aortic aneurysm formation from healthy controls.

Enterocutaneous fistula occurring 10 years after an open umbilical hernia repair with placement of an onlay polypropylene mesh: A case report

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An enterocutaneous fistula is a rare complication that can arise many years after an umbilical hernia repair.

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Recurrence of the hernia may be a predisposing factor leading to mesh erosion into the underlying structures.

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Modification of repair technique and mesh type and location may aid in reducing the incidence of an enterocutaneous fistula.

Introduction

Ventral hernia repair is a common surgical procedure performed within the specialty of general surgery. Short and long term complications can arise after this procedure. Although rare, an enterocutaneous fistula may occur, leading to a significant morbidity and the possible need for surgical intervention.

Presentation of case

We present a rare case of a 76 years old female, who presented with the sudden occurrence of an enterocutaneous fistula arising ten years after a primary umbilical hernia repair with placement of a polypropylene onlay mesh. She was also found to have a large recurrent umbilical hernia. She underwent a laparotomy with the identification of a mesh eroding into the small bowel lumen, causing an enterocutaneous fistula. An enterectomy was performed to remove the fistula with the mesh, and a small bowel anastomosis was created.

Discussion

Ventral hernia recurrence is associated with risk factors including old age, obesity, wound infection as well as the type and location of the mesh used. As in this case, enterocutaneous fistula after hernia repair can occur due to multiple factors including mesh migration and erosion into near-by structures including bowel. These risk factors can perhaps be modified to possibly reduce the incidence of complications like an enterocutaneous fistula.

Conclusion

The case highlights a rare but serious complication associated with a ventral hernia repair. It also addresses key aspects with regards to the possible mechanisms involved in the occurrence of an enterocutaneous fistula following a hernia repair with the use of a synthetic mesh.

Predictors and Outcomes of Paramedian Incisional Hernia After Anterior Spine Exposure

BACKGROUND

Anterior exposures for lumbar spine surgery are increasingly common for treating various spinal pathologies. A retroperitoneal approach via a paramedian incision has grown rapidly in popularity, but little is known about the risk of incisional hernia development with this technique. We sought to assess the incidence of paramedian incisional hernia development and identify risk factors that are associated with occurrence.

MATERIALS AND METHODS

We conducted a retrospective review of all patients who underwent anterior lumbar spine exposure by a paramedian approach between 2012 and 2017 at a single, tertiary medical center. The primary outcome was the development of postoperative paramedian incisional hernia.

RESULTS

Of the 735 patients included in the study, 445 (60.5%) were women, and the mean (standard deviation) age of all patients was 60 y (12.4). Nearly all (97.4%) paramedian approaches were performed with a vascular surgeon present. Median follow-up time was 10 mo (interquartile range 3.5-19.9). Postoperative paramedian hernia developed in 20 patients (2.7%), of which 14 underwent repair. The mean (standard deviation) size of the hernia was 13.5 cm (5.5); 9 of 14 (64%) were repaired with synthetic mesh, whereas 3 of 14 (21%) required bowel resection. On multivariate analysis, risk factors associated with hernia development were male gender (0.045), higher American Society of Anesthesiologists class (0.039), history of abdominal surgery (P = 0.013), and postoperative intensive care unit admission (P = 0.02).

CONCLUSIONS

A paramedian approach for anterior lumbar spine exposure resulted in a low rate of incisional hernia with minimal morbidity. Surgeons involved in these collaborative procedures should consider the risk factors that predispose patients to develop these hernias.

Prophylactic Mesh for Hernia Prevention: Has the Time Arrived?

Incisional and parastomal hernias continue to be vexing problems for patients and surgeons. Risk factors are generally patient-related and/or technical in nature, and in some cases, can be altered, resulting in improved outcomes. Improved fascial closure techniques can only partly reduce the risk of incisional hernia formation. Even under optimal circumstances, using time tested closure techniques and materials, the rate remains high, due primarily to factors that are not modifiable or are unidentifiable. In such cases, there may be a beneficial role for prophylactic mesh augmentation (PMA), wherein mesh is implanted at the time of initial surgery or stoma formation. Several high-risk groups that might benefit from PMA have been identified, including patients undergoing open abdominal aneurysm repair or colorectal procedures, obese patients, and patients requiring creation of permanent gastrointestinal or urological stomas. Although the initial results of PMA are promising, the benefits of this strategy must be weighed against potential risks. Outcome measures to assess efficacy should include not only hernia recurrence but also quality of life, surgical-site occurrences, and cost. Further studies are warranted to predict which specific patient populations might benefit most from PMA and to identify ideal mesh materials as well as preferred implantation sites and methods of mesh fixation.

Prophylactic Intraperitoneal Onlay Mesh Reinforcement Reduces the Risk of Incisional Hernia, Two-Year Results of a Randomized Clinical Trial

BACKGROUND

Incisional hernias still are a major concern after laparotomy and are causing substantial morbidity. This study examines the feasibility, safety and incisional hernia rate of the use of a prophylactic intraperitoneal onlay mesh stripe (IPOM) to prevent incisional hernia following midline laparotomy.

METHODS

This prospective, randomized controlled trial randomly allocated patients undergoing median laparotomy either to mass closure of the abdominal wall with a PDS-loop running suture reinforced by an intraperitoneal composite mesh stripe (Group A) or to the same procedure without the additional mesh stripe (Group B). Primary endpoint was the incidence of incisional hernias at 2 years following midline laparotomy. Secondary endpoints are were the feasibility, the safety of the mesh stripe implantation including postoperative pain, and the incidence of incisional hernias at 5 years.

RESULTS

A total of 267 patients were included in this study. Follow-up data 2 years after surgery was available from 210 patients (Group A = 107; Group B = 103). An incisional hernia was diagnosed in 18/107 (17%) patients in Group A and in 40/103 (39%) patients in Group B (p < 0.001). A surgical operation due to an incisional hernia was conducted for 12/107 (11%) patients in Group A and for 24/103 (23%) patients in Group B (p = 0.039). In both groups, minor and major complications as well as postoperative pain are reported with no statistically significant difference between the groups, even in contaminated situations.

CONCLUSIONS

This first randomized clinical trial indicates that the placement of a non-absorbable IPOM-stripe with prophylactic intention may significantly reduce the risk for a midline incisional hernia.

TRIAL REGISTRATION

Ref. NCT01003067 (clinicaltrials.gov).

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

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

The State of Prophylactic Mesh Augmentation

Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and clinicaltrials.gov for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only–based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.

Short-term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation to prevent incisional hernia

BACKGROUND

Incisional hernia is one of the most frequent postoperative complications after abdominal surgery. Patients with an abdominal aortic aneurysm and patients with a body mass index of 27 or higher have an increased risk to develop incisional hernia. Primary mesh augmentation is a method in which the abdominal wall is strengthened to reduce incisional hernia incidence. This study focused on the short-term results of the PRImary Mesh Closure of Abdominal Midline Wounds trial, a multicenter double blind randomized controlled trial.

METHODS

Between 2009 and 2012 patients were included if they were operated via midline laparotomy, and had an abdominal aortic aneurysm or a body mass index of 27 or higher. Patients were randomly assigned to either receive primary suture, onlay mesh augmentation (OMA), or sublay mesh augmentation.

RESULTS

Outcomes represent results after 1-month follow-up. A total of 480 patients were randomized. During analysis, significantly (P = 0.002) more seromas were detected after OMA (n = 34, 18.1%) compared with primary suture (n = 5, 4.7%) and sublay mesh augmentation (n = 13, 7%). No differences were discovered in any of the other outcomes such as surgical site infection, hematoma, reintervention, or readmission. Multivariable analysis revealed an increase in seroma formation after OMA with an odds ratio of 4.3 (P = 0.004) compared with primary suture and an odds ratio of 2.9 (P = 0.003) compared with sublay mesh augmentation.

CONCLUSIONS

On the basis of these short-term results, primary mesh augmentation can be considered a safe procedure with only an increase in seroma formation after OMA, but without an increased risk of surgical site infection.

Analysis of perioperative factors associated with increased cost following abdominal wall reconstruction (AWR)

BACKGROUND

Ventral hernias are a common, challenging, and expensive problem for both the general and reconstructive surgeons; therefore, the aim of this study is to critically assess perioperative factors related to cost in abdominal wall reconstructions (AWR).

METHODS

A retrospective review of AWR patients from 2007 and 2012 was performed. Analysis of perioperative factors associated with total cost of reconstruction was performed. Linear regression analyses were used to assess independent predictors of total cost.

RESULTS

134 consecutive AWR performed by a single surgeon over a 5-year period at an academic teaching center were included. The average total cost of AWR was $61,251 ± 55,624. Linear regression analysis demonstrated that diabetes (P = 0.026), increased American Society of Anesthesiologists score (P = 0.002), preoperative anemia (P = 0.001), and hernias derived from trauma (P = 0.015) were independently associated with added cost in AWR when controlling for confounding variables. In addition, patients requiring intra-abdominal procedures (P = 0.012) and those receiving an AWR using Acellular Dermal Matrix (P = 0.015) accrued significantly greater cost. Interestingly, preoperative placement of an epidural (P = 0.011) was independently associated with significant cost savings and reduced medical morbidity. Major surgical complications (P < 0.001) and length of stay (P < 0.001) were independently associated with increased cost following AWR.

CONCLUSION

We present a critical assessment of cost in AWR at a major academic teaching hospital and quantify the impact of reconstruction in the setting of medical morbidities and reconstructive complexities. The data from this study can be used to adjust reimbursement schemes and to critically assess the cost-benefit of performing AWR.

Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia. A randomized clinical trial

BACKGROUND

Prosthetic repair has become the standard method for hernia repair. Mesh placement for the prevention of trocar site incisional hernia (TSIH) is still a controversial issue. We tested the hypothesis that closure with an intraperitoneal prophylactic mesh of the umbilical trocar after a laparoscopic cholecystectomy can reduce the incidence of a TSIH in high-risk patients.

STUDY DESIGN

A randomized clinical trial was conducted among patients undergoing elective laparoscopic cholecystectomy who presented the following high-risk factors for incisional hernia, according to the literature: age 65 years and older, diabetes mellitus, chronic pulmonary disease, and obesity (ie, body mass index ≥30 kg/m(2)). Patients were assigned to have closure of the umbilical trocar site with either nonabsorbable sutures (group A) or intraperitoneal polypropylene omega-3 mesh (group B). Trocar site incisional hernia, pain, and surgical complications were evaluated at the early postoperative course and at 1, 6, and 12 months after surgery.

RESULTS

A total of 106 patients were randomized into the study and 92 patients were finally analyzed, including 47 in group A and 45 in group B. The TSIH rate was higher in group A (31.9%) than in group B (4.4%) (odds ratio = 10.1; 95% CI, 2.15-47.6; p < 0.001)). The wound infection rate was 4.3%; 8.5% in group A and 0% in group B (odds ratio = 2.04; 95% CI, 1.7-2.5; p = 0.045). Median postoperative pain evaluated by a visual analogue scale was 3 in group A and 2 in group B (p = 0.05). No differences were observed in complication rate, operative time, or hospital stay between the groups.

CONCLUSIONS

Prosthetic closure of the umbilical trocar site after laparoscopic surgery could become the standard method for preventing TSIH in high-risk patients.

A novel technique for modified onlay incisional hernia repair with mesh incorporation into the fascial defect: a method for addressing suture line failure

PURPOSE

Biological mechanisms such as abnormal wound healing and impaired scar formation are important aetiological factors in the development of abdominal wall hernias. Standard onlay repair often involves suture closure of the fascial defect with placement of the mesh over this closed defect. This has the disadvantage that suture line failure may occur early in the healing process and predispose to recurrence. Our technique aims to overcome this by incorporating the mesh into the fascial closure. The aim of this retrospective study was to audit recurrence rate and surgical complications relating to this modified repair.

METHODS

This study included all patients undergoing incisional hernia repair over a 5-year period under a single consultant. An initial stitch was taken through the Ultrapro(TM) mesh and fascia on one side of the defect followed by the fascia and mesh on the other side. By repeating this process with a continuous suture, the mesh was incorporated into the fascial defect closure. Telephone survey was performed, and where there was suspicion of a recurrence patients were brought back to the outpatient clinic.

RESULTS

The study included 72 patients with a median follow-up of 29 months. There was a 7 % recurrence rate and a 10 % minor complication rate, with no patient requiring readmission or mesh removal. In 70 % of patients the procedure was performed as a day case and 90 % were satisfied with the repair.

CONCLUSIONS

This is a promising new technique that aims to address suture line failure and the significant recurrence rate that occurs with incisional hernia repair.

Cost effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing permanent colostomy for rectal cancer

BACKGROUND

Parastomal hernia (PSH) is common after stoma formation. Studies have reported that mesh prophylaxis reduces PSH, but there are no cost-effectiveness data. Our objective was to determine the cost effectiveness of mesh prophylaxis vs no prophylaxis to prevent PSH in patients undergoing abdominoperineal resection with permanent colostomy for rectal cancer.

STUDY DESIGN

Using a cohort Markov model, we modeled the costs and effectiveness of mesh prophylaxis vs no prophylaxis at the index operation in a cohort of 60-year-old patients undergoing abdominoperineal resection for rectal cancer during a time horizon of 5 years. Costs were expressed in 2012 Canadian dollars (CAD$) and effectiveness in quality-adjusted life years. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

In patients with stage I to III rectal cancer, prophylactic mesh was dominant (less costly and more effective) compared with no mesh. In patients with stage IV disease, mesh prophylaxis was associated with higher cost (CAD$495 more) and minimally increased effectiveness (0.05 additional quality-adjusted life years), resulting in an incremental cost-effectiveness ratio of CAD$10,818 per quality-adjusted life year. On sensitivity analyses, the decision was sensitive to the probability of mesh infection and the cost of the mesh, and method of diagnosing PSH.

CONCLUSIONS

In patients undergoing abdominoperineal resection with permanent colostomy for rectal cancer, mesh prophylaxis might be the less costly and more effective strategy compared with no mesh to prevent PSH in patients with stage I to III disease, and might be cost effective in patients with stage IV disease.

Single-port Roux-en-Y gastric bypass: toward a less invasive procedure with the same surgical results and a better cosmesis

BACKGROUND

The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach.

METHODS

A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m(2), and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device.

RESULTS

The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m(2), and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m(2) (range, 18-35 kg/m(2)). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose.

CONCLUSIONS

Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach.