Suture Versus Mesh Repair in Primary and Incisional Ventral Hernias: A Systematic Review and Meta-Analysis

Maximizing mesh mileage: evaluating the long-term performance of a novel hybrid mesh for ventral hernia repair

PURPOSE

The objective of this study is to evaluate the safety and long-term outcomes of GORE Synecor™ in ventral hernia repair (VHR).

METHODS

This retrospective, single-center case review analyzed outcomes in patients who underwent VHR with Synecor from May 2016 to December 2022. Primary outcomes were hernia recurrence and mesh infection rates. Secondary outcomes were 30-day morbidity, 30-day mortality, 30-day readmission, re-operation, surgical-site infection (SSI) and occurrence (SSO) rates, and occurrences requiring intervention (SSOI).

RESULTS

278 patients were identified. Mean follow-up was 24.1 (0.2-87.1) months. Mean hernia defect size was 63.4 (± 77.2) cm2. Overall hernia recurrence and mesh infection rates were 5.0% and 1.4% respectively. No mesh infections required full explantation. We report the following overall rates: 13.3% 30-day morbidity, 4.7% 30-day readmission, 2.9% re-operation, 7.2% SSI, 6.1% SSO, and 2.9% SSOI. 30-day morbidity was significantly higher in non-clean (42.1% vs 11.2%, p < 0.01), onlay (OL) mesh (37.0% vs preperitoneal (PP) 16.4%, p = 0.05 vs retrorectus (RR) 15.0%, p < 0.05 vs intraperitoneal (IP) 5.2%, p < 0.001), and open cases (23.5% vs 3.1% laparoscopic vs 4.4% robotic, p < 0.01). SSI rates were significantly higher in non-clean (31.6% vs 5.4%, p < 0.001), OL mesh (29.6% vs RR 11.3%, p < 0.05 vs PP 5.5%, p < 0.01 vs IP 0.0%, p < 0.001), and open cases (15.2% vs 0% laparoscopic vs 0% robotic, p < 0.05).

CONCLUSION

Long-term performance of a novel hybrid mesh in VHR demonstrates a low recurrence rate and favorable safety profile in various defect sizes and mesh placement locations.

Mesh versus suture for elective primary umbilical hernia open repair: a systematic review and meta-analysis

PURPOSE

Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR.

METHODS

We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%.

RESULTS

2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay.

CONCLUSION

The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the suture repair, no differences were seen after subgroup analysis of RCTs.

STUDY REGISTRATION

A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

Topical antimicrobial treatment of mesh for the reduction of surgical site infections after hernia repair: a systematic review and meta-analysis

PURPOSE

Use of mesh is essential in hernia repair. A common complication after hernia repair is surgical site infection (SSI), which poses a risk in spreading to the mesh, possibly causing mesh infection. Topical antimicrobial pretreatment of mesh may potentially reduce SSI risk in hernia repair and has shown promising results in in vitro and in vivo studies. Clinical evidence, however, is more important. This systematic review aims to provide an overview of available clinical evidence for antimicrobial pretreated mesh in hernia repair surgery to reduce SSI.

METHODS

We report in accordance with PRISMA guidelines. CENTRAL, EMBASE, CINAHL and PubMed were searched up to October 2023 for studies that investigated the use of antimicrobial pretreated mesh on SSI incidence in adults undergoing hernia repair. The primary outcome was SSI incidence. We also collected data on pathogen involvement, hernia recurrence, and mesh infection. A meta-analysis on SSI risk and GRADE-assessment was performed of eligible studies.

RESULTS

We identified 11 eligible studies (n = 2660 patients); 5 randomized trials and 6 cohort studies. Investigated interventions included pre-coated mesh, antibiotic carriers, mesh soaked or irrigated with antibiotic or antiseptic solution. Meta-analysis showed no significant reduction in SSI for antibiotic pretreated polypropylene mesh (RR 0.76 [95% CI 0.27; 2.09]; I2 50%).

CONCLUSION

Data on topical mesh pretreatment to reduce SSI risk after hernia repair is limited. Very low certainty evidence from randomized trials in hernia repair surgery shows no significant benefit for antibiotic mesh pretreatment for SSI reduction, but data are imprecise due to optimal information size not being met.

Does intraperitoneal mesh increase the risk of bowel obstruction? A nationwide French analysis

INTRODUCTION

Incisional hernias are associated with a reduced quality of life. Mesh reinforcement of the abdominal wall is the current standard for incisional hernia repair (IHR), since it reduces the risk of recurrence. The best position for the mesh remains controversial, and each position has advantages and disadvantages.

OBJECTIVE

In this nationwide population-based study, we aimed to determine whether IHR with intraperitoneal mesh is associated with an increased risk of bowel obstruction.

PATIENTS AND METHODS

Using the French hospital database (PMSI), which collects data from all public and private hospitals, two patient cohorts were created and compared. Patients having undergone a laparoscopic IHR with intraperitoneal mesh (IPOM) in 2013 or 2014 due to a laparotomy performed in the 4 previous years were the IPOM group. Patients hospitalized for any other acute disease (i.e., without IHR) in 2013 and 2014, but having a similar laparotomy in the 4 previous years were the control group. Both cohorts were followed until 2019 in search of any episode of bowel obstruction.

RESULTS

A total of 815 patients were included in the IPOM group and matched to 1630 control patients. The 5 year bowel obstruction rate was 7.36% in the IPOM group and 4.42% in the control group (p < 0.01). In the multivariate analysis, after adjustment on age and obesity, incisional hernia repair with laparoscopic IPOM increased the risk of bowel obstruction in the 5 years following surgery (HR = 1.712; 95% CI 1.208-2.427; p = 0.0025).

CONCLUSIONS

Patients having undergone laparoscopic IPOM have an increased risk of bowel obstruction compared with patients who have a similar surgical history but no IHR.

Evaluation of Extracellular Matrix Remodeling in Full-thickness Skin Grafts in Mice

Abdominal hernia is a protruding weakness in the abdominal wall. It affects abdominal strength and life quality and can lead to complications due to intestinal entrapment. Autologous full-thickness skin graft (FTSG) has recently become an alternative material for reinforcement in the surgical repair of large abdominal hernias instead of synthetic mesh. FTSG eventually integrates with the abdominal wall, but the long-term fate of the graft itself is not fully understood. This has implications as to how these grafts should be optimally used and handled intraoperatively. This study investigates the remodeling of FTSG in either the onlay or the intraperitoneal position 8 weeks after FTSG transplantation in an experimental mouse model. There was a significant presence of fibroblasts, indicated by vimentin and S100A4 staining, but there were significant variations among animals as to how much of the graft had been remodeled into dense connective tissue. This correlated significantly with the proportion of vimentin-positive cells in the dense connective tissue. We also found that collagen hybridizing peptide staining intensity, a marker of active remodeling, was significantly associated with the proportion of S100A4-positive cells in the dense connective tissue of the FTSG.

Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction

PURPOSE

Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages.

METHODS

A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy.

RESULTS

Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05).

CONCLUSION

Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.

Investigation of optimal hernia repair techniques in patients with inflammatory bowel disease

INTRODUCTION

Multiple laparotomies, immunosuppressive therapy, wound infection, and malnutrition are risk factors for incisional hernia development, which places inflammatory bowel disease (IBD) patients at high risk. With advances in minimally invasive techniques, this study assesses incisional hernia repair techniques and complications in the IBD population.

METHODS

A single-center, retrospective review of adults with IBD who underwent incisional hernia repair from 2008 to 2022. Complications relative to operative approach and mesh placement location were assessed using descriptive and univariate statistics.

RESULTS

Eighty-eight IBD patients underwent incisional hernia repair. Fifty-two (59.1%) were on immunomodulators and 30 (34.1%) were repaired primarily. Thirty-five (39.7%) hernias recurred, of whom 19 (33%) had mesh placed. Three (30%) occurred in onlay repairs and 16 (33%) occurred in underlay repairs. Subdivision of underlay repairs into intraperitoneal, preperitoneal and retrorectus mesh placement revealed recurrence rates of 35.1%, 50%, and 14.3%, respectively. Patients with open repair were more likely to have intraoperative bowel injury (28.6% vs 9.7%, p = 0.041) and develop postoperative seromas/abscesses (12.5% vs 0%, p = 0.001) and wound complications (17.9% vs 0%, p = 0.012) compared to laparoscopic. Seromas/abscesses developed more frequently in onlay repairs compared to underlay (40% vs 2.13%, p = 0.001). Twelve (13.6%) patients presented with postoperative small bowel obstruction (SBO), 7 (58.3%) of whom had mesh placed, and 6 (85.7%) were underlay. All SBO after underlay repair had intraperitoneally placed mesh. When comparing surgeons, hernias were more likely to recur performed by colorectal surgeons compared to hernia surgeons (63.3% vs 21.3%, p < 0.001).

CONCLUSION

In IBD patients, minimally invasive approaches lead to fewer perioperative complications compared to open. Underlay mesh placement demonstrated decreased incidence of seroma/abscess formation compared to onlay. When sub-grouped, underlay placements were similar in terms of complications. Retrorectus placement, however, had fewer recurrences and no readmissions for SBO. This suggests a minimally invasive approach or placement of retrorectus mesh may provide the optimal repair in this patient population.

Primary Lumbar Hernia, Review and Proposals for a Standardized Treatment

A lumbar abdominal wall hernia is a protrusion of intraperitoneal or extraperitoneal contents through a weakness in the posterior abdominal wall, usually through the superior or inferior lumbar triangle. Due to its rare occurrence, adequate knowledge of anatomy and methods for optimal diagnosis and treatment might be lacking with many surgeons. We believe a clear understanding of anatomy, a narrative review of the literature and a pragmatic proposal for a step-by-step approach for treatment will be helpful for physicians and surgeons confronted with this condition. We describe the anatomy of this condition and discuss the scarce literature on this topic concerning optimal diagnosis and treatment. Thereafter, we propose a step-by-step approach for a surgical technique supported by intraoperative images to treat this condition safely and prevent potential pitfalls. We believe this approach offers a technically easy way to perform effective reinforcement of the lumbar abdominal wall, offering a low recurrence rate and preventing important complications. After meticulously reading this manuscript and carefully following the suggested approach, any surgeon that is reasonably proficient in minimally invasive abdominal wall surgery (though likely not in lumbar hernia surgery), should be able to treat this condition safely and effectively. This manuscript cannot replace adequate training by an expert surgeon. However, we believe this condition occurs so infrequently that there is likely to be a lack of real experts. This manuscript could help guide the surgeon in understanding anatomy and performing better and safer surgery.

Five-Year Follow-Up of a Slowly Resorbable Biosynthetic P4HB Mesh (Phasix) in VHWG Grade 3 Incisional Hernia Repair

Objective

To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh.

Summary Background Data

Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12-18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce.

Methods

Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0-10].

Results

In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55-64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9-24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0-2).

Conclusions

Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index >28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection.

Primary Uncomplicated Ventral Hernia Repair: Guidelines and Practice Patterns for Routine Hernia Repairs

Surgical repair of primary umbilical and epigastric hernias are among the most common abdominal operations in the world. The hernia defects range from small (<1 cm) to large and complex even in the absence of prior incision or repair. Mesh has generally been shown to decrease recurrence rates, and its use and location of placement should be individualized for each patient. Open, laparoscopic, and robotic approaches provide unique considerations for the technical aspects of primary repair with or without mesh augmentation.

Suture versus open mesh repair for small umbilical hernia: Results of a propensity-matched cohort study

BACKGROUND

The objective was to compare the outcomes of open mesh repair versus suture repair for small (≤1 cm in diameter) umbilical hernia. The primary endpoint was the 30-day outcomes including pain, and secondary endpoints were the 2-year outcomes including recurrences and patient-reported outcomes.

METHODS

This propensity-matched, multicenter study was carried out on data collected prospectively in the Hernia-Club database between 2011 and 2021. A total of 590 mesh repairs and 590 suture repairs were propensity score matched (age, sex, body mass index) at a ratio of 1:1. Postoperative pain was assessed using the Verbal Rating Scale-4 and 0‒10 Numerical Rating Scale-11.

RESULTS

Mesh insertion was intraperitoneal in 331 patients (56.1%), extraperitoneal in 249 (42.2%), and onlay in 10 (1.7%). The rate of 30-day complications and Numerical Rating Scale-11 pain scores on postoperative days 8 and 30 were similar between the groups, including surgical site occurrences (2.2 vs 1.4% after suture repair). At 1 month, postoperative discomfort (sensation of something different from before) was significantly (P < .0001) more frequent after mesh repair, whereas the rate of relevant (moderate or severe) pain (mesh repair: 1.1% vs suture repair: 2.6%) and the distribution of Numerical Rating Scale-11 scores did not differ between the groups. At the 2-year follow-up, mesh repair patients had fewer reoperated recurrences (0.2% vs 1.7%; P = .035) and no more pain or discomfort than suture repair patients.

CONCLUSION

Both techniques are effective and safe. Mesh repair is likely to reduce the rate of recurrences. Concerns about postoperative pain and infection might not prevent the use of mesh in smallest umbilical hernias.

Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields

BACKGROUND

Prophylactic intra-abdominal onlay mesh (IPOM) implantation has been shown to reduce the rate of fascial dehiscence and incisional hernia. However, surgical site infection (SSI) in presence of an IPOM remains a concern. The aim of this study was to assess predictors for SSI following IPOM placement in hernia and non-hernia abdominal surgery in clean and contaminated surgical fields.

METHODS

Observational study including patients undergoing IPOM placement at a Swiss tertiary care hospital 2007-2016. IPOM implantation was performed in hernia and non-hernia elective and emergency abdominal surgery, including contaminated and infected surgical fields. The incidence of SSI was prospectively assessed by Swissnoso according to CDC criteria. The effect of disease- and procedure-related factors on SSI was assessed in multivariable regression analysis, adjusting for patient-related factors.

RESULTS

A total of 1072 IPOM implantations were performed. Laparoscopy was performed in 415 patients (38.7%), laparotomy in 657 patients (61.3%). SSI occurred in 172 patients (16.0%). Superficial, deep, and organ space SSI were found in 77 (7.2%), 26 (2.4%), and 69 (6.4%) patients, respectively. Multivariable analysis revealed emergency hospitalization (OR 1.787, p = 0.006), previous laparotomy (1.745, p = 0.029), duration of operation (OR 1.193, p < 0.001), laparotomy (OR 6.167, p < 0.001), bariatric (OR 4.641, p < 0.001), colorectal (OR 1.941, p = 0.001), and emergency (OR 2.510, p < 0.001) surgery, wound class ≥ 3 (OR 3.878, p < 0.001), and non-polypropylene mesh (OR 1.818, p = 0.003) as independent predictors for SSI. Hernia surgery was independently associated with a lower risk for SSI (OR 0.165, p < 0.001).

CONCLUSION

This study revealed emergency hospitalization, previous laparotomy, duration of operation, laparotomy, as well as bariatric, colorectal, and emergency surgery, abdominal contamination or infection, and usage of non-polypropylene mesh as independent predictors for SSI. In contrast, hernia surgery was associated with a lower risk for SSI. The knowledge of these predictors will help to balance benefits of IPOM implantation against the risk for SSI.

Biologic Versus Synthetic Mesh in Ventral Hernia Repair: Participant-Level Analysis of Two Randomized Controlled Trials at Twenty-Four to Thirty-Six Months

Background: Biologic mesh has been used increasingly in complex ventral hernia repair despite limited evidence at low risk of bias supporting its use. Patients and Methods: We performed a participant-level analysis of published randomized controlled trials (RCTs) comparing biologic to synthetic mesh with complex ventral hernia repair at 24 to 36 months. Primary outcome was major complication (composite of mesh infection, recurrence, reoperation, or death) at 24 to 36 months post-operative. Secondary outcomes included length of index hospital stay, surgical site occurrence, surgical site infection, and death. Outcomes were assessed using both frequentist and Bayesian generalized linear regression models. Results: A total of 252 patients from two RCTs were included, 126 patients randomized to the intervention arm of biologic and 126 patients to the control of synthetic mesh with median follow-up of 29 (23, 38) months. Major complication occurred in 33 (33%) patients randomized to biologic, and 39 (38%) patients randomized to synthetic mesh, (relative risk [RR] 0.91, 95% confidence interval [CI] 0.63-1.31; p value = 0.600). Bayesian analysis demonstrated that compared with synthetic mesh, biologic mesh had similar probability of major complications at 24 to 36 months post-operative. The remainder of outcomes demonstrated slight benefit with synthetic mesh as opposed to biologic mesh except for mesh infection. However, under a frequentist framework, no outcome was statistically different. Conclusions: In patients undergoing open ventral hernia repair, there was no benefit for patients receiving biologic versus synthetic mesh at 24 to 36 months post-operative.

Abdominal Wall Reconstruction with Retrorectus Self-Adhering Mesh: A Single-Center Long-Term Follow-Up

BACKGROUND

Mesh repair has been demonstrated to be superior to suture alone in ventral hernia repair. In a previous short-term pilot study, the authors found lower postoperative narcotic requirements with self-adhering mesh. The aim of this study was to follow-up on that pilot study, using long-term data.

METHODS

This is a retrospective review of a prospectively collected database. All patients who underwent ventral hernia repair with retrorectus mesh and who had at least a 12-month follow-up were reviewed. Comparisons were performed between patients who received self-adhering mesh and those who received transfascially sutured mesh, using matched-pair analysis, examining perioperative outcomes, surgical-site occurrences, and hernia recurrence/bulge.

RESULTS

Forty-two patients were included in the study, with 21 patients undergoing repair with transfascially sutured mesh and 21 patients receiving self-adhering mesh. Average length of follow-up was 1078 days. There were no significant differences between the two groups in baseline characteristics. Patients receiving self-adhering mesh had significantly shorter surgery, and a shorter hospital length of stay. They also had a tendency toward lower narcotic requirements. There were no significant differences in the rate of surgical-site occurrences, hernia recurrences, or bulge between the two groups.

CONCLUSIONS

This long-term study shows that self-adhering mesh in ventral hernia repair results in similar long-term outcomes to transfascially sutured mesh, with shorter surgery, shorter length of stay, and a tendency toward improved pain control. These findings mirror the known advantages of self-adhering mesh in inguinal hernia repair. Further research is needed to study the incidence of chronic pain and the cost-effectiveness of self-adhering mesh.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Open versus laparoscopic intraperitoneal on-lay mesh repair: A comparison of outcomes in small ventral hernia

PURPOSE

The ideal surgical treatment of small ventral hernias (defect less than 4 cm) is still debatable. In our study, we sought to compare the outcomes of open versus laparoscopic intraperitoneal on-lay mesh (IPOM) repair in small ventral hernias.

METHODS

Patients with a single ventral hernia defect of less than 4 cm undergoing surgical mesh repair between January 2016 and September 2018 were prospectively registered for this study. The minimum follow-up duration was 12 months. Patient demographics, operative findings and regular post-operative follow-up details including recurrence rates and complications were recorded and analysed.

RESULTS

41 patients underwent laparoscopic IPOM repair and 47 patients underwent open IPOM repair. The mean age for both groups is similar with no significant difference. The mean hernia defect size for the laparoscopic group is 2.8 cm (±0.8) whereas the mean hernia defect size for the open repair group is 2.1 cm (±0.4). The mean surgery duration for open IPOM repair was significantly shorter (59 min (±17) vs 74 min (±26); p = 0.001). There was no significant difference in the incidence of seroma formation and surgical site infections post-operatively. There was also no significant difference in both groups in terms of chronic pain and recurrence at 1-year follow-up.

CONCLUSION

Open IPOM repair for small ventral hernias may be superior to laparoscopic IPOM repair due to the shorter operative duration, single incision, and no additional risk of port-site hernias. There was no difference in chronic pain, wound infection and recurrence rate between the two groups.

Hernia recurrence after primary repair of small umbilical hernia defects

BACKGROUND

An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined.

METHODS

A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications.

RESULTS

Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant.

CONCLUSIONS

With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.

Tension-reduced closure of large abdominal wall defect caused by shotgun wound: A case report

BACKGROUND

Large abdominal wall defect (LAWD) caused by shotgun wound is rarely reported.

CASE SUMMARY

Herein, we describe a case of LAWD caused by a gunshot wound in which the abdominal wall was reconstructed in stages, including debridement, tension-reduced closure (TRC), and reconstruction with mesh and a free musculocutaneous flap. During a 3-year follow-up, the patient recovered well without hernia or other problems.

CONCLUSION

TRC is a practical approach for the temporary closure of LAWD, particularly in cases when one-stage abdominal wall restoration is unfeasible due to significant comorbidities.

A Biomechanical Analysis of Prophylactic Mesh Reinforced Porcine Laparotomy Incisions

INTRODUCTION

Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing.

METHODS

In each specimen, a 10-cm incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5 cm, 3 cm, 4 cm, 6 cm, 8 cm) and tack separation (1.5 cm, 2 cm apart) and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 N to 140 N were applied to simulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed.

RESULTS

All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4-cm mesh specimens (567.51 N) than those with suture, 2.5-cm, and 3.0-cm mesh (all P < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance.

CONCLUSIONS

A 4-cm mesh reenforcement was superior to suture-only and smaller meshes at preserving strength in laparotomy closure in a porcine model but larger meshes (6 cm, 8 cm) did not provide an additional benefit. Meshes with more fixation points may be advantageous, but additional data are needed to make definitive conclusions.

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.

Are Surgeons of the Abdominal Core Health Quality Collaborative Following Guidelines in Umbilical and Epigastric Hernia Repair?

BACKGROUND

Umbilical and epigastric hernias are among the top three most common hernia surgeries performed in the USA with varied techniques. The European and Americas Hernia Societies (EAHS) recently published guidelines for repair of umbilical and epigastric hernias. We evaluated how closely the general surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and to identify areas for possible improvement.

METHOD

Data from patients undergoing elective and emergent umbilical or epigastric hernia repair from 2013 to 2021 were extracted from the ACHQC database. The procedures performed on eligible subjects were compared to those proposed by the EAHS guidelines. Data was reported as a percentage and a cutoff of 70% was selected to determine compliance.

RESULTS

Based on these criteria, 11,088 patients were included and most of the recommendations, including appropriate preoperative antibiotic dosing (96.1% umbilical; 97.2% epigastric), permanent mesh selection (umbilical 97.8%; 96.1 epigastric), mesh fixation with suture (83.6% umbilical; 75.5% epigastric), use of mesh for open repair of hernias greater than 1 cm (83.6 umbilical; 85.7 epigastric), and primary defect closure during open (98.6% umbilical; 97.5% epigastric) and laparoscopic (99.6% umbilical; 100% epigastric) repair, were met.

DISCUSSION

Surgeons of the ACHQC adhere to most of the published guidelines on umbilical and epigastric hernia repair. Further research is needed to reinforce or modify the existing recommendations. Standardization of surgical approach will facilitate additional research needed to improve procedural efficiency, while reducing negative outcomes and cost.

Bovine versus porcine acellular dermal matrix for abdominal wall herniorrhaphy or bridging

BACKGROUND

The management of complicated ventral hernias (CVH), namely ventral hernias in actively or recently infected/contaminated operative fields, and open abdomens in which the native fascia cannot be primarily reapproximated, pose a surgical challenge. Fetal Bovine and Porcine Acellular Dermal Matrix (BADM and PADM) biologic meshes are being increasingly used in these scenarios. A comparison, however, of clinically relevant outcomes between the two is lacking. With this investigation, we aim to review and compare clinically relevant outcomes in patients that underwent abdominal wall herniorrhaphy with either BADM or PADM at a tertiary urban academic institution over a 5-year period.

METHODS

Patients who had a BADM or PADM implanted during CVH over a 5-year period at a tertiary urban academic hospital were identified. Baseline clinical and hernia characteristics, as well as postoperative outcomes were compared after a retrospective chart review. Phone interviews were also conducted to assess for recurrence, followed by in-person visits as indicated. Cox Proportional Hazard regression was fitted to identify risk factors for recurrence.

RESULTS

Of the 140 patients who underwent biologic mesh implantation for CVH, 109 were for ventral hernia repair and 31 for open abdomen bridging. Mean age was 52.7 ± 14.2 and males constituted 57.9% of our sample, while 25.1% had undergone > 5 prior abdominal operations. Thirty percent were active smokers, and another 30% required emergency surgery. Only immunosuppression was a risk factor for recurrence [HR 13.3 (1.04-169.2), p = 0.047] on Cox Proportional Hazard regression, while mesh selection had no effect.

CONCLUSIONS

Both BADM and PADM meshes perform well in CVH, with satisfactory recurrence rates, only slightly higher compared to traditional synthetic mesh repairs.

Incisional hernia repair with a slowly absorbable P4HB mesh: what happens after the mesh disappears? A retrospective longitudinal clinical study

PURPOSE

To analyze the incisional hernia recurrence rate at a long-term follow-up using a biosynthetic long-term absorbable mesh in patients with a higher risk of surgical infection in a contaminated surgical field.

METHODS

This was a retrospective multicentric study. All patients undergoing incisional hernia repair between 2016 and 2018 at 6 participating university centers were included. Patients were classified according to the Ventral Hernia Working Group (VHWG). All consecutive patients who underwent abdominal wall repair using biosynthetic long-term absorbable mesh (Phasix^®) in contaminated fields (grade 3 and 4 of the VHWG classification) were included. Patients were followed-up until September 2021. Preoperative, operative, and postoperative data were collected. All patients' surgical site infections (SSIs) and surgical site occurrences (SSOs) were recorded. The primary outcome of interest was the clinical incisional hernia recurrence rate.

RESULTS

One hundred and eight patients were included: 77 with VHWG grade 3 (71.3%) and 31 with VHWG grade 4 (28.7%). Median time follow-up was 41 months [24; 63]. Twenty-four patients had clinical recurrence during the follow-up (22.2%). The SSI and SSO rates were 24.1% and 36.1%, respectively. On multivariate analysis, risk factors for incisional hernia recurrence were previous recurrence, mesh location, and postoperative enterocutaneous fistula.

CONCLUSIONS

At the 3 year follow-up, the recurrence rate with a biosynthetic absorbable mesh (Phasix^®) for incisional hernia repair in high-risk patients (VHWG grade 3 and 4) seemed to be suitable (22.2%). Most complications occurred in the first year, and SSI and SSO rates were low despite high-risk VHWG grading.

Defining Wider Indications for Stoppa Repair Other Than Recurrent Hernias

Managing complex inguinal hernias has been a constant challenge for surgeons and its treatment is not without challenges with the routine current techniques. Complex inguinal hernias especially recurrent have been managed by the Rives-Stoppa technique which is an established suture-less, tension-free, and absolute method of treatment with minimal recurrence rates. Traditionally, this surgical technique is most indicated in recurrent inguinal hernias, but we aim to assess the usefulness of this procedure for the treatment of complex inguinal hernias in individuals presenting for the first time. We report four varied cases of complex inguinal hernias, repaired by the open Rives-Stoppa technique, and discuss its indications, technique of repair, and current status.

Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP

AIM

The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions.

METHODS

The review was based on current national and international guidelines and a literature search.

RESULTS

Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair.

DISCUSSION

The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.

Evaluation of the Sublay Mesh Repair Outcomes in Different Types of Ventral Hernia

Introduction: Ventral hernia repair is one of the challenging surgical operations over time. Several surgical techniques for mesh repair have been described (onlay, inlay, sublay, and underlay repairs). It is suggested that sublay mesh repair has the lowest recurrence and surgical site infection in open anterior abdominal hernia repair. This study aimed to analyze the pros and cons of the sublay mesh in ventral hernia repair to evaluate the significance of this technique as a treatment modality. Hospital stay, acute postoperative complications, and the recurrence rate were the main areas of investigation.

Methods: A retrospective study on 79 patients with ventral hernias who were operated on with sublay mesh repair between January 2015 and December 2018 was conducted. Patients were admitted through the elective route. The study included fit patients with first-time ventral hernias (primary and incisional). Recurrent hernia, patients with decompensated cardiopulmonary disorders, and bleeding disorders were excluded from the project. The project pro forma includes patient’s demographics, operative details, length of stay, postoperative complications, and follow-up up to 12 months.

Results: All patients underwent open mesh repair using the sublay technique. The ventral hernia was five times more common in females than males. The mean age of presentation was 44.8 years old. The mean operating time was 67 minutes and a one-day hospital stay. Paraumblical and incisional hernias represented the majority of cases. The component separation approach was added in three cases (3.7%). Simultaneous cholecystectomy was performed in two cases (2.5%). Only six cases (6.3%) developed wound-related complications, while two cases (2.5%) had a recurrence.

Conclusion: The sublay mesh repair is a perfect choice for the repair of ventral abdominal hernia. It is associated with a smooth and short hospital stay and the least incidence of complications and recurrence.

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.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques

SUMMARY

Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Slowly resorbable biosynthetic mesh: 2-year results in VHWG grade 3 hernia repair

Introduction

Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix™) over 24 months.

Methods

A prospective, international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm², scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months.

Results

Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery.

Conclusion

After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations.

Trial registration

Registered on clinicaltrials.gov (NCT02720042), March 25, 2016.

Laparoscopic Ventral Hernia Repair with Poly-4-Hydroxybutyrate Absorbable Barrier Composite Mesh

Background

Repair of ventral and incisional hernias (VIHR) is a common procedure, newly introduced resorbable mesh biomaterials provide an attractive option to reduce the use of permanent synthetic mesh in hernia surgery and reduce its complications. However, data on the use of slowly resorbable mesh materials remains scarce, this study aims to evaluate the use of poly-4-hydroxybutyrate/absorbable barrier composite mesh (P4HB/ABCM) in laparoscopic repair of VIHR.

Methods

This is a retrospective study of a sequential cohort of patients undergoing laparoscopic VIHR utilizing a P4HB/ABCM mesh. Perioperative characteristics and clinical outcomes were collected.

Results

In total, 26 patients including 10 females and 7 males underwent laparoscopic VIHR using P4HB/ABCM. All surgeries were performed in a single institution by the same surgeon. The average patient age was 52.6, and the mean BMI was 35.5. All patients had a clean wound classification. The average defect size was 136.4 cm². All patients were seen in clinic with a median follow-up of 28 months. We observed 4 wound seromas, and no wound infections or recurrences during the follow-up period.

Conclusion

Results of laparoscopic VIHR with P4HB/ABCM are favorable and encourages further studies on the role of absorbable biosynthetic mesh materials in hernia surgery.

Mesh fixation techniques in primary ventral or incisional hernia repair

BACKGROUND

The use of a mesh in primary ventral or incisional hernia repair lowers the recurrence rate  and is the accepted standard of care for larger defects. In laparoscopic primary ventral or incisional hernia repair the insertion of a mesh is indispensable. Different mesh fixation techniques have been used and refined over the years. The type of fixation technique is claimed to have a major impact on recurrence rates, chronic pain, health-related quality of life (HRQOL) and complication rates.

OBJECTIVES

To determine the impact of different mesh fixation techniques for primary and incisional ventral hernia repair on hernia recurrence, chronic pain, HRQOL and complications.

SEARCH METHODS

On 2 October 2020 we searched CENTRAL, MEDLINE (Ovid MEDLINE(R)) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)), Ovid Embase, and two trials registries. We also performed handsearches, and contacted experts from the European Hernia Society (EHS).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including adults with primary ventral or incisional hernia that compared different types of mesh fixation techniques (absorbable/nonabsorbable sutures, absorbable/nonabsorbable tacks, fibrin glue, and combinations of these techniques).

DATA COLLECTION AND ANALYSIS

We extracted data in standardised piloted tables, or if necessary, directly into Review Manager 5. We assessed risks of bias with the Cochrane 'Risk of bias' tool. Two review authors independently selected the publications, and extracted data on results. We calculated risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes. For pooling we used an inverse-variance random-effects meta-analysis or the Peto method in the case of rare events. We prepared GRADE 'Summary of findings' tables. For laparoscopic repair we considered absorbable tacks compared to nonabsorbable tacks, and nonabsorbable tacks compared to nonabsorbable sutures as key comparisons.

MAIN RESULTS

We included 10 trials with a total of 787 participants. The number of randomised participants ranged from 40 to 199 per comparison. Eight studies included participants with both primary and incisional ventral hernia. One study included only participants with umbilical hernia, and another only participants with incisional hernia. Hernia size varied between studies. We judged the risk of bias as moderate to high. Absorbable tacks compared to nonabsorbable tacks Recurrence rates in the groups were similar (RR 0.74, 95% confidence interval (CI) 0.17 to 3.22; 2 studies, 101 participants). It is uncertain whether there is a difference between absorbable tacks and nonabsorbable tacks in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Nonabsorbable tacks compared to nonabsorbable sutures At six months there was one recurrence in each group (RR 1.00, 95% CI 0.07 to 14.79; 1 study, 36 participants). It is uncertain whether there is a difference between nonabsorbable tacks and nonabsorbable sutures in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up and chronic pain is negligible. We found no study that assessed HRQOL. Absorbable tacks compared to absorbable sutures No recurrence was observed at one year (very low certainty of evidence). Early postoperative pain was higher in the tacks group (VAS 0 - 10: MD -2.70, 95% CI -6.67 to 1.27; 1 study, 48 participants). It is uncertain whether there is a difference between absorbable tacks compared to absorbable sutures in early postoperative pain because the certainty of evidence was very low. The MD for late follow-up pain was -0.30 (95% CI -0.74 to 0.14; 1 study, 48 participants). We found no study that assessed HRQOL. Combination of different fixation types (tacks and sutures) or materials (absorbable and nonabsorbable) There were mostly negligible or only small differences between combinations (e.g. tacks plus sutures) compared to a single technique (e.g. sutures only), as well as combinations compared to other combinations (e.g. absorbable sutures combined with nonabsorbable sutures compared to absorbable tacks combined with nonabsorbable tacks) in all outcomes. It is uncertain whether there is an advantage for combining different fixation types or materials for recurrence, chronic pain, HRQOL and complications, because the evidence certainty was very low or low, or we found no study on important outcomes. Nonabsorbable tacks compared to fibrin sealant The two studies showed different directions of effects: one showed higher rates for nonabsorbable tacks, and the other showed higher rates for fibrin sealant. Low-certainty evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Absorbable tacks compared to fibrin sealant One recurrence in the tacks group and none in the fibrin sealant group were noted after one year (low certainty of evidence). Early postoperative pain might be slightly lower using tacks (VAS 0 - 100; MD -12.40, 95% CI -27.60 to, 2.80;1 study, 50 participants; low-certainty evidence). The pattern of pain and HRQOL course over time (up to 1 year) was similar in the groups (low certainty of evidence).

AUTHORS' CONCLUSIONS

Currently none of the techniques can be considered superior to any other, because the certainty of evidence was low or very low for all outcomes.

Early Clinical and Patient-Reported Outcomes of a New Hybrid Mesh for Incisional Hernia Repair

INTRODUCTION

Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, Synecor^TM, for Ventral Hernia Repair (VHR).

METHODS

Adult (>18 y old) patients undergoing VHR with Synecor^TM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL.

RESULTS

Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m², respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05).

CONCLUSIONS

Abdominal reinforcement with Synecor^TM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.

Postoperative Abdominal Bulge and Hernia Rates in Patients Undergoing Abdominally Based Autologous Breast Reconstruction: Systematic Review and Meta-Analysis

ABSTRACT

Bulge and hernia may occur after abdominally based breast reconstruction. The purpose of this study is to provide an estimate of the effects that the type of flap used for breast reconstruction (ie, transverse rectus abdominis muscle [TRAM] vs muscle-sparing [MS]-2 TRAM vs DIEP) has on the postoperative development of both abdominal bulge and abdominal hernia, taking into consideration the method of donor site closure (ie, with mesh vs without mesh), based on the available literature. Twenty-eight studies met the inclusion criteria and were included in the systematic review. From these, 9 studies were comparative and suitable for meta-analysis. The results showed that, for unilateral breast reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flap without mesh, MS-2 TRAM flap with mesh, and DIEP flap without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flap without mesh, and TRAM flap with mesh, whereas for bilateral reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flaps with mesh and DIEP flaps without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flaps without mesh, TRAM flaps with mesh, and MS-2 TRAM flaps without mesh.

What is the outcome of the open IPOM versus sublay technique in the treatment of larger incisional hernias?: A propensity score-matched comparison of 9091 patients from the Herniamed Registry

INTRODUCTION

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. This analysis of data from the Herniamed Registry aimed to compare the outcomes of open IPOM and sublay technique.

METHODS

Propensity score matching of 9091 patients with elective incisional hernia repair and with defect width ≥ 4 cm was performed. The following matching variables were selected: age, gender, risk factors, ASA score, preoperative pain, defect size, and defect localization.

RESULTS

For the 1977 patients with open IPOM repair and 7114 patients with sublay repair, n = 1938 (98%) pairs were formed. No differences were seen between the two groups with regard to the intraoperative, postoperative and general complications, complication-related reoperations and recurrences. But significant disadvantages were identified for the open IPOM repair in respect of pain on exertion (17.1% vs. 13.7%; p = 0.007), pain at rest (10.4% vs. 8.3%; p = 0.040) and chronic pain requiring treatment (8.8% vs. 5.8%; p < 0.001), in addition to rates of 3.8%, 1.1% and 1.1%, respectively, occurring in both matched patients. No relationship with tacker mesh fixation was identified. There are only very few reports in the literature with comparable findings.

CONCLUSION

Compared with sublay repair, open IPOM repair appears to pose a higher risk of chronic pain. This finding concords with the Expert Consensus recommending that incisional hernia should preferably be repaired using the sublay technique.

Treatment of small (< 2 cm) umbilical hernias: guidelines and current trends from the Herniamed Registry

INTRODUCTION

Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2 cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2 cm) umbilical hernias over the past 10 years.

METHODS

Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented.

RESULTS

A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2 cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2 cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013.

CONCLUSIONS

A suture technique is still used to treat 75% of patients with small (< 2 cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.

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.

Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias

OBJECTIVES

described by Dr. Jorge Daes, principles of the enhanced view totally extraperitoneal (eTEP) has been widely used in the armamentarium of ventral hernia repair recently. Robotic assisted eTEP technique feasibility has been proved, however, a complete understanding of retromuscular abdominal wall planes and its landmarks still uncertain in a majority of general surgeons. The aim of this report is to propose a technical standardization and its anatomic concepts in the robotic-assisted eTEP ventral hernia repair.

METHODS

our group describes 10 key steps in a structured step-by-step approach for a safe and reproducible repair based on well defined anatomic landmarks, identification of zones of dissection and correct restoration of the linea alba.

RESULTS

the standardization has been developed 2 years ago and applied to all patients. A robotic-assisted surgery with 3 robotic arms is performed in a lateral docking setup. Feasibility is established and reproducibility is high among general surgeons.

CONCLUSION

we present a standardized side docking robotic assisted eTEP approach for ventral hernia repairs with 10 key steps. We believe understanding the landmarks and a step-by-step guidance based on the concepts of retromuscular abdominal wall anatomy foment a safe learning of minimally invasive restoration of the abdominal wall integrity regarding non-expert surgeons.

Assessment of potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair: a registry-based multivariable analysis of 31,965 patients

INTRODUCTION

How best to treat a small (< 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors.

METHODS

The data of patients with primary elective umbilical hernia repair and defect size < 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up.

RESULTS

31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates.

CONCLUSION

Suture repair continues to be used for 78% of umbilical hernias with a defect < 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).

Outcomes of a new slowly resorbable biosynthetic mesh (Phasix™) in potentially contaminated incisional hernias: A prospective, multi-center, single-arm trial

BACKGROUND

Resorbable biomaterials have been developed to reduce the amount of foreign material remaining in the body after hernia repair over the long-term. However, on the short-term, these resorbable materials should render acceptable results with regard to complications, infections, and reoperations to be considered for repair. Additionally, the rate of resorption should not be any faster than collagen deposition and maturation; leading to early hernia recurrence. Therefore, the objective of this study was to collect data on the short-term performance of a new resorbable biosynthetic mesh (Phasix™) in patients requiring Ventral Hernia Working Group (VHWG) Grade 3 midline incisional hernia repair.

MATERIALS AND METHODS

A prospective, multi-center, single-arm trial was conducted at surgical departments in 15 hospitals across Europe. Patients aged ≥18, scheduled to undergo elective Ventral Hernia Working Group Grade 3 hernia repair of a hernia larger than 10 cm² were included. Hernia repair was performed with Phasix™ Mesh in sublay position when achievable. The primary outcome was the rate of surgical site occurrence (SSO), including infections, that required intervention until 3 months after repair.

RESULTS

In total, 84 patients were treated with Phasix™ Mesh. Twenty-two patients (26.2%) developed 32 surgical site occurrences. These included 11 surgical site infections, 9 wound dehiscences, 7 seromas, 2 hematomas, 2 skin necroses, and 1 fistula. No significant differences in surgical site occurrence development were found between groups repaired with or without component separation technique, and between clean-contaminated or contaminated wound sites. At three months, there were no hernia recurrences.

CONCLUSION

Phasix™ Mesh demonstrated acceptable postoperative surgical site occurrence rates in patients with a Ventral Hernia Working Group Grade 3 hernia. Longer follow-up is needed to evaluate the recurrence rate and the effects on quality of life. This study is ongoing through 24 months of follow-up.

Dual Tack Mesh Fixation System on a Cadaveric Porcine Model-Creation of a Mesh Fixation System for Hernia Treatment and Prevention

BACKGROUND

Onlay mesh repair (OMR) has proven to be a widely used, simple, and effective technique for treatment and prevention of hernia occurrence. Despite established benefits, there is still a lack of widespread adoption. In this study, we present the Dual Tacker Device (DTD), an enabling technology that directly addresses the limitations to the adoption of OMR, saving surgical time and effort and making OMR more reproducible across a wide range of patients.

METHODS

The DTD mesh fixation system is a semiautomated, hand-held, disposable, multipoint onlay mechanical mesh fixation system that is able to rapidly and uniformly tension and fixate mesh for both hernia treatment and prevention. A cadaveric porcine model was used as a pilot test conducted during a 2 day session to assess the usability of the device and to show that the DTD provided equivalent or superior biomechanical support compared with the standard of care (hand-sewn, OptiFix).

RESULTS

Our study included 37 cadaveric porcine incisional closure abdominal wall models. These were divided into four groups: DTD-mediated OMR (n = 14), hand-sewn OMR (n = 7), OptiFix OMR (n = 9), and suture-only repair (no mesh) (n = 7). Eight surgical residents performed device-mediated and hand-sewn OMR. Average time to completion was fastest in the DTD cohort (45.6s) with a statistically significant difference compared with the hand-sewn cohort (343.1s, P < 0.01). No difference in tensile strength was noted between DTD (195.32N), hand-sewn (200.48N), and OptiFix (163.23N). Discreet hand movements were smallest in the DTD (29N) and significant (P < 0.01) when compared with hand-sewn (202N) and OptiFix (35N).

CONCLUSIONS

The use of the DTD is not only feasible, but demonstrated improvement in time to completion and economy of movement over current standard of care. While more testing is needed and planned, compared with conventional approaches, the DTD represents a robust proof of principle with promising implications for clinical feasibility and adoptability.

Non-coated versus coated mesh for retrorectus ventral hernia repair: a propensity score-matched analysis of the Americas Hernia Society Quality Collaborative (AHSQC)

PURPOSE

The outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space.

METHODS

Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI).

RESULTS

3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group.

CONCLUSION

Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.

Ventral hernia repair by totally extraperitoneal approach (VTEP): technique description and feasibility study

BACKGROUND

The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results.

METHODS

The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed.

RESULTS

98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1-50) cm² and 225 (50-500) cm², respectively. The mean operation duration was 75 (30-270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0-8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1-15) days and 11.5 (1-30) days, respectively.

CONCLUSION

Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies.

Is mesh always necessary in every small umbilical hernia repair? Comparison of standardized primary sutured versus patch repair: retrospective cohort study

Purpose

A retrospective analysis was carried out to compare the results of patch repair using ready-made, synthetic mesh (PR) and sutured repair (SR) based on standard protocols. The accumulated recurrence rate was accepted as the primary outcome. Pain at rest and during exercise, cosmetic effect and treatment satisfaction were chosen as the secondary endpoints.

Methods

Adult patients after elective, open surgical repair of a single, primary umbilical hernia < 2 cm in diameter were included. Patients with incarceration or strangulation, after previous umbilical hernia repair or other abdominal surgical interventions were excluded. In the SR group, single-layer sutures were placed using the short-stitch technique. In PR group, a 6.3-mm ready-made Parietene Ventral Patch (Medtronic) was used.

Results

161 patients (104 in PR and 57 in SR groups) were included in the study (22 months follow-up). Nine recurrences were observed [six in PR (5.8%) and three in SR group (5.2%)]. In PR group, three patients (2.9%) reported complaints at rest and none in SR group, while 18 patients (17.3%) in PR group reported pain during exercises and 7 (12.3%) in SR group.

Conclusion

For the smallest umbilical hernias, the use of dense fascia suturing (short-stitch technique) may be an effective alternative to patch repair techniques in patients with no additional risk factors for recurrence. The mesh patch repair method is associated with a significantly higher risk of postsurgical pain. Diastasis recti is a factor favoring umbilical hernia recurrence after both pure tissue repair and patch repair.

Regulation of Peritoneal Inflammatory Response to Implant Material Using an Ex Vivo Model System

BACKGROUND

Implants used in abdominal wall reconstruction are associated with intra-abdominal inflammation that can cause complications such as adhesions, fistulae, or failure of the implant. This study analyzed the inflammatory response of human peritoneum explants when exposed to different implant materials including synthetic and biological (cross-linked and non-cross-linked).

MATERIALS AND METHODS

Human peritoneum explants (parietal and visceral) were incubated in culture with implants used for abdominal wall reconstruction. Implants included Permacol (biological implant with chemical cross-linking); Biodesign and Strattice (biological implants without chemical cross-linking); Prolene (synthetic nonabsorbable); and Vicryl (synthetic absorbable). Control peritoneum samples were incubated without implant. Cytokine concentrations and corresponding gene expression were measured by enzyme-linked immunosorbent assay and quantitative polymerase chain reaction, respectively. Further evaluation included assessment of tissue viability and implant-cytokine adsorption.

RESULTS

Incubation of human peritoneal explants with Biodesign or Strattice was associated with a significant reduction in interleukin-6, interleukin-1β, and tumour necrosis factor alpha protein and gene expression compared with control. These could not be explained by reduced cell viability or implant-cytokine adsorption. Incubation of explants in Biodesign-conditioned media displayed a similar effect to incubation of explants with Biodesign itself.

CONCLUSIONS

Human peritoneal explants cultured with different mesh implant materials show an altered inflammatory cytokine response suggesting a tissue-specific response. Downregulation of key inflammatory cytokines by the peritoneum exposed to non-cross-linked biological implants may be mediated by the release of soluble factors from these implants inhibiting cytokine gene expression. This ex vivo human peritoneal system provides a novel preclinical model to investigate peritoneum-implant interactions.

Absorbable Polyglactin vs. Non-Cross-linked Porcine Biological Mesh for the Surgical Treatment of Infected Incisional Hernia

BACKGROUND

The use of absorbable meshes during contaminated or infected incisional hernia (IH) repair is associated with high morbidity and recurrence rates. Biological meshes might be more appropriate but have been described in highly heterogeneous series. This study aimed at comparing the efficacy of absorbable vs. biological meshes for the treatment of contaminated or infected IH in a homogeneous series with a standardized technique.

METHODS

Data of all patients operated on between 2008 and 2015 for contaminated or infected IH, using an absorbable (A) Vicryl® or a biological (B) Strattice® mesh, were reviewed. Patient characteristics, infectious complication rates, and recurrence-free outcome (RFO) were compared between the two groups. A propensity score methodology was applied to a Cox regression model to deal with unbalanced characteristics between groups.

RESULTS

Patient demographics in A (n = 57) and in B (n = 24) were similar except that B patients had larger parietal defects (p < 0.001) and higher Center for Disease Control (CDC) wound class (p = 0.034). Patients in A had statistically significantly more postoperative early (61.4% vs. 33.3%, p = 0.03) and late (31.2% vs. 8.3%, p = 0.046) infectious complications. Six-, 12-, and 36-month RFO rates were 77%, 47%, and 24%, and 96%, 87%, and 82% in A and B, respectively, p < 0.001. Raw multivariable Cox regression analysis found that B (HR = 0.1, 95% CI [0.03-0.34], p < 0.001) was independently associated with prolonged RFO (HR = 0.091, 95% CI [0.045-0.180], p < 0.001).

CONCLUSION

Biological meshes seem to be superior to absorbable meshes in patients with contaminated or infected incisional hernia. These results need to be confirmed by prospective randomized trials.

Mesh-preservation approach to treatment of mesh infection after large incisional ventral hernia repair-how I do it

Mesh infection after large incisional ventral hernia repair is a clinical dilemma in abdominal wall hernia surgery. It is believed foreign material should be removed but it causes secondary trauma to the abdominal wall tissue and might be associated with a higher risk of complications. Currently, there is no consensus on mesh-preservation treatment in cases of mesh infection after hernia repair in general. Herein we present the case of a 27-year-old male who recovered well from mesh infection after large incisional ventral hernia repair by mesh-preservation approach. The path to success is choice of material of prosthetic mesh; surgical approach of hernia repair, sufficient wound irrigation and drainage, and acquiring sterility of the mesh surface by wound care techniques such as local iodophor packing and vacuum sealing drainage. Clinical cohorts are needed to verify the feasibility of mesh-preservation treatment of mesh infection after large incisional hernia repair.

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.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

BACKGROUND

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias.

METHODS

The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019.

RESULTS

Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity.

CONCLUSION

This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.