A randomised, multi-centre, prospective, observer and patient blind study to evaluate a non-absorbable polypropylene mesh vs. a partly absorbable mesh in incisional hernia repair

Heavyweight versus non-heavyweight mesh in ventral hernia repair: a systematic review and meta-analysis

PURPOSE

There is considerable variability among surgeons regarding the type of mesh used in ventral hernia repair. There has been an increasing incidence of mesh fractures with lightweight (LW) and mediumweight (MW) meshes. However, HW mesh has been associated with a greater foreign body sensation and chronic pain. This meta-analysis aims to compare the outcomes of HW and non-heavyweight (NHW) meshes in ventral hernia repair.

METHODS

We systematically reviewed the PubMed, Embase, Cochrane, and Scopus databases to identify studies comparing HW with NHW meshes in hernia repair. Outcomes analyzed included hernia recurrence, seroma, hematoma, foreign body sensation, postoperative pain, and wound infection. We performed two subgroup analyses focusing on randomized controlled trials and open retromuscular repairs. Statistical analysis was performed using RevMan 5.4.

RESULTS

We screened 1704 studies. Nine studies were finally included in this meta-analysis and comprised 3001 patients from 4 RCTs and 5 non-randomized. The majority of patients (57.1%) underwent open retromuscular repair. HW mesh was significantly associated with increased in foreign body sensation (OR 3.71; 95% CI 1.40-9.84; p = 0.008), but there was no difference in other outcomes. In RCTs analysis, there was no difference between meshes. In open retromuscular repairs, HW mesh was associated with more seromas (OR 1.48; 95% CI 1.01-2.17; p = 0.05).

CONCLUSION

Our study found that HW mesh was associated with more foreign body sensation. Also, open retromuscular repairs analysis showed that HW was associated with more seromas. Further randomized studies are needed to understand better the role of HW mesh in ventral hernia repair.

Comparison of Different Weight Meshes in Ventral/Incisional Hernia Repair, the Outcomes of Systematic Review and Meta-analysis

BACKGROUND

The use of mesh is not without complications. Decreasing the mesh weight with the light-weight (LW) mesh may improve tissue growth and diminish mesh-related complications, yet, clinically, there are conflicting results regarding the influence of different weight meshes in ventral/incisional hernia repair. The aim of the present study is to compare the outcomes of different weight meshes for ventral/incisional hernia repair.

METHODS

The major databases (PubMed, Embase, Springer, and Cochrane Library) were searched, and all studies were published through January 1, 2022, using the keywords "heavy weight" "light weight" "mesh" "ventral hernia" "incisional hernia". All relevant articles and reference lists in these original studies were also obtained from the above databases.

RESULTS

Eight trials (4 randomized controlled trials, 3 prospective studies, and 1 retrospective study) containing 1844 patients were included in the present meta-analysis. The pooled results showed that there was a significantly more rate of foreign body perception in the heavy-weight mesh group compared with the LW mesh group (odds ratio = 5.02, 95% CI: 1.05, 24.06). There was no significant difference concerning hernia recurrence, seroma, hematoma, surgical site infection, reoperation rate, chronic pain, quality of life, and hospital stay among different weight mesh groups.

CONCLUSION

Different weight meshes showed similar clinical results in ventral/incisional hernia repair, except that, perception of foreign body was reported more frequently in the heavy-weight mesh group as compared with the LW mesh group. However, the long-term hernia recurrence with different weights of meshes needs to be reevaluated considering the relative short-term follow-up in these studies.

Effect of Hernia Mesh Weights on Postoperative Patient-Related and Clinical Outcomes After Open Ventral Hernia Repair: A Randomized Clinical Trial

Importance

Although multiple versions of polypropylene mesh devices are currently available on the market for hernia repair, few comparisons exist to guide surgeons as to which device may be preferable for certain indications. Mesh density is believed to impact patient outcomes, including rates of chronic pain and perception of mesh in the abdominal wall.

Objective

To examine whether medium-weight polypropylene is associated with less pain at 1 year compared with heavy-weight mesh.

Design, Setting, and Participants

This multicenter randomized clinical trial was performed from March 14, 2017, to April 17, 2019, with 1-year follow-up. Patients undergoing clean, open ventral hernia repairs with a width 20 cm or less were studied. Patients were blinded to the intervention.

Interventions

Patients were randomized to receive medium-weight or heavy-weight polypropylene mesh during open ventral hernia repair.

Main Outcomes and Measures

The primary outcome was pain measured with the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Short Form 3a. Secondary outcomes included quality of life and pain measured at 30 days, quality of life measured at 1 year, 30-day postoperative morbidity, and 1-year hernia recurrence.

Results

A total of 350 patients participated in the study, with 173 randomized to receive heavy-weight polypropylene mesh (84 [48.6%] female; mean [SD] age, 59.2 [11.4] years) and 177 randomized to receive medium-weight polypropylene mesh (91 [51.4%] female; mean [SD] age, 59.3 [11.4] years). No significant differences were found in demographic characteristics (mean [SD] body mass index of 32.0 [5.4] in both groups [calculated as weight in kilograms divided by height in meters squared] and American Society of Anesthesiologists classes of 2-4 in both groups), comorbidities (122 [70.5%] vs 93 [52.5%] with hypertension, 44 [25.4%] vs 43 [24.3%] with diabetes, 17 [9.8%] vs 12 [6.8%] with chronic obstructive pulmonary disease), or operative characteristics (modified hernia grade of 2 in 130 [75.1] vs 140 [79.1] in the heavy-weight vs medium-weight mesh groups). Pain scores for patients in the heavy-weight vs medium-weight mesh groups at 30 days (46.3 vs 46.3, P = .89) and 1 year (30.7 vs 30.7, P = .59) were identical. No significant differences in quality of life (median [interquartile range] hernia-specific quality of life score at 1 year of 90.0 [67.9-96.7] vs 86.7 [65.0-93.3]; median [interquartile range] hernia-specific quality of life score at 30 days, 45.0 [24.6-73.8] vs 43.3 [28.3-65.0]) were found for the heavy-weight mesh vs medium-weight mesh groups. Composite 1-year recurrence rates for patients in the heavy-weight vs medium-weight polypropylene groups were similar (8% vs 7%, P = .79).

Conclusions and Relevance

Medium-weight polypropylene did not demonstrate any patient-perceived or clinical benefit over heavy-weight polypropylene after open retromuscular ventral hernia repair. Long-term follow-up of these comparable groups will elucidate any potential differences in durability that have yet to be identified.

Trial Registration

ClinicalTrials.gov Identifier: NCT03082391.

A systematic review of outcome reporting in incisional hernia surgery

Background

The incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies.

Methods

Literature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included.

Results

In total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used.

Conclusions

This review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair

BACKGROUND

Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes.

METHODS

A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed.

RESULTS

Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes.

CONCLUSION

Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

Repair of complex abdominal wall hernias with a cross-linked porcine acellular matrix: cross-sectional results of a Dutch cohort study

BACKGROUND

The use of synthetic mesh in potentially contaminated and contaminated incisional hernias may lead to a higher morbidity and mortality. Biological meshes may provide a solution, but since these meshes are rarely used, little is known about long-term results. The aim of this cohort study was to evaluate the long-term clinical efficacy and patient satisfaction following Permacol™ in complex abdominal wall hernia repair (CAWHR) patients in a cross-sectional fashion.

MATERIALS AND METHODS

All patients were operated for CAWHR with Permacol™ in the Netherlands between 2009 and 2012. The design was a multicenter cross-sectional cohort study. The STROCSS statement was followed. Patients were interviewed, underwent abdominal examination, and completed quality-of-life questionnaires. ClinicalTrials.gov Identifier NCT02166112. Research Registry Identifier researchregistry4713.

RESULTS

Seventy-seven patients were seen in the outpatient clinic. Their hernias were classified as potentially contaminated in 25 patients (32.5%) and infected in 52 patients (67.5%). The mean follow-up was 22.2 ± 12.6 months. The most frequent postoperative complication was wound infection (n = 21; 27.3%), meshes had to be removed in five patients (6.5%). By the time of their visit to the outpatient clinic, 22 patients (28.6%) had a recurrence of whom ten (13%) had undergone reoperation. Thirty-nine patients (50.6%) had bulging of the abdominal wall. Quality-of-life questionnaires revealed that patients graded their health status with a mean 6.8 (± 1.8) out of 10 points.

CONCLUSION

Bulging and recurrence are frequently observed in patients treated with Permacol™ for CAWHR. Considering both recurrence and bulging as undesirable outcomes of treatment, a total of 46 patients (59.7%) had an unfavorable outcome. Infection rates were high, but comparable with similar patient cohorts. Quality-of-life questionnaires revealed that patients were satisfied with their general health, but scored significantly lower on most quality-of-life modalities of the Short Form-36 questionnaire.

Use of imaging for pre- and post-operative characterisation of ventral hernia: systematic review

OBJECTIVE

Complex ventral hernia (CVH) repair is performed increasingly, exacerbated by the obesity epidemic. Imaging can characterise hernia morphology and diagnose recurrence. By systematic review we investigated the extent to which studies employ imaging.

METHODS

The PubMed database was searched for studies of ventral hernia repair from January 1995 to March 2016. Hernias of all size were eligible. Independent reviewers screened articles and extracted data from selected studies related to study design, use of pre- and post-operative hernia imaging and the proportion of subjects imaged. The review was registered: PROSPERO CRD42016043071.

RESULTS

15,771 records were identified initially. 174 full-texts were examined and 158 ultimately included in the systematic review [31 randomised controlled trials (RCTs); 32 cohort studies; 95 retrospective cohort studies]. 31,874 subjects were reported overall. Only 19 (12%) studies employed pre-operative imaging for hernia characterisation and 46 (29%) post-operatively [equating to 511 (2%) of all pre-operative subjects and 1123 (4%) post-operative]. Furthermore, most studies employing imaging did not do so in all subjects: Just 6 (4%) of the 158 studies used imaging in all subjects pre-operatively and just 4 (3%) post-operatively, i.e. imaging was usually applied to a proportion of patients only. Moreover, the exact proportion was frequently not specified. Studies using imaging frequently stated that "imaging", "radiography" or "radiology" was used but did not specify the modality precisely nor the proportion of subjects imaged.

CONCLUSION

Despite the ability to characterise ventral hernia morphology and recurrence with precision, most indexed studies do not employ imaging. Where imaging is used, data are often reported incompletely. Advances in knowledge: (1) This systematic review is the first to focus on the use of imaging in surgical studies of ventral hernia repair. (2) Studies of ventral hernia repair rarely use imaging, either to characterise hernias pre-operatively or to diagnose recurrence, despite the latter being the primary outcome of most studies. (3) Failure to use imaging will result in incomplete hernia characterisation and underestimate recurrence rates in studies of surgical repair.

What Is the Current Knowledge About Sublay/Retro-Rectus Repair of Incisional Hernias?

Introduction: There continues to be very little agreement among experts on the precise treatment strategy for incisional hernias. That is the conclusion drawn from the very limited scientific evidence available on the repair of incisional hernias. The present review now aims to critically assess the data available on the sublay/retro-rectus technique for repair of incisional hernia. Materials and Methods: A systematic search of the literature was performed in May 2018 using Medline, PubMed, and the Cochrane Library. This article is based on 77 publications. Results: The number of available RCTs that permit evaluation of the role of the sublay/retro-rectus technique in the repair of only incisional hernia is very small. The existing data suggest that the sublay/retro-rectus technique has disadvantages compared with the laparoscopic IPOM technique for repair of incisional hernia, but in that respect has advantages over all other open techniques. However, the few existing studies provide only a limited level of evidence for assessment purposes. Conclusion: Further RCTs based on a standardized technique are urgently needed for evaluation of the role of the sublay/retro-rectus incisional hernia repair technique.

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

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

A systematic methodological review of reported perioperative variables, postoperative outcomes and hernia recurrence from randomised controlled trials of elective ventral hernia repair: clear definitions and standardised datasets are needed

BACKGROUND

This systematic review assesses the perioperative variables and post-operative outcomes reported by randomised controlled trials (RCTs) of VH repair. This review focuses particularly on definitions of hernia recurrence and techniques used for detection.

OBJECTIVE

Our aim is to identify and quantify the inconsistencies in perioperative variable and postoperative outcome reporting, so as to justify future development of clear definitions of hernia recurrence and a standardised dataset of such variables.

METHODS

The PubMed database was searched for elective VH repair RCTs reported January 1995 to March 2016 inclusive. Three independent reviewers performed article screening, and two reviewers independently extracted data. Hernia recurrence, recurrence rate, timing and definitions of recurrence, and techniques used to detect recurrence were extracted. We also assessed reported post-operative complications, standardised operative outcomes, patient reported outcomes, pre-operative CT scan hernia dimensions, intra-operative variables, patient co-morbidity, and hernia morphology.

RESULTS

31 RCTs (3367 patients) were identified. Only 6 (19.3%) defined hernia recurrence and methods to detect recurrence were inconsistent. Sixty-four different clinical outcomes were reported across the RCTs, with wound infection (30 trials, 96.7%), hernia recurrence (30, 96.7%), seroma (29, 93.5%), length of hospital stay (22, 71%) and haematoma (21, 67.7%) reported most frequently. Fourteen (45%), 11 (35%) and 0 trials reported CT measurements of hernia defect area, width and loss of domain, respectively. No trial graded hernias using generally accepted scales.

CONCLUSION

VH RCTs report peri- and post-operative variables inconsistently, and with poor definitions. A standardised minimum dataset, including definitions of recurrence, is required.

Initial Experience With Biologic Polymer Scaffold (Poly-4-hydroxybuturate) in Complex Abdominal Wall Reconstruction

OBJECTIVE

To evaluate the use of the new absorbable polymer scaffold poly-4-hydroxybutyrate (P4HB) in complex abdominal wall reconstruction.

BACKGROUND

Complex abdominal wall reconstruction has witnessed tremendous success in the last decade after the introduction of cadaveric biologic scaffolds. However, the use of cadaveric biologic mesh has been expensive and plagued by complications such as seroma, infection, and recurrent hernia. Despite widespread application of cadaveric biologic mesh, little data exist on the superiority of these materials in the setting of high-risk wounds in patients. P4HB, an absorbable polymer scaffold, may present a new alternative to these cadaveric biologic grafts.

METHODS

A retrospective analysis of our initial experience with the absorbable polymer scaffold P4HB compared with a consecutive contiguous group treated with porcine cadaveric mesh for complex abdominal wall reconstructions. Our analysis was performed using SAS 9.3 and Stata 12.

RESULTS

The P4HB group (n = 31) experienced shorter drain time (10.0 vs 14.3 d; P < 0.002), fewer complications (22.6% vs 40.5%; P < 0.046), and reherniation (6.5% vs 23.8%; P < 0.049) than the porcine cadaveric mesh group (n = 42). Multivariate analysis for infection identified: porcine cadaveric mesh odds ratio 2.82, length of stay odds ratio 1.11; complications: drinker odds ratio 6.52, porcine cadaveric mesh odds ratio 4.03, African American odds ratio 3.08, length of stay odds ratio 1.11; and hernia recurrence: porcine cadaveric mesh odds ratio 5.18, drinker odds ratio 3.62, African American odds ratio 0.24. Cost analysis identified that P4HB had a $7328.91 financial advantage in initial hospitalization and $2241.17 in the 90-day postdischarge global period resulting in $9570.07 per case advantage over porcine cadaveric mesh.

CONCLUSIONS

In our early clinical experience with the absorbable polymer matrix scaffold P4HB, it seemed to provide superior clinical performance and value-based benefit compared with porcine cadaveric biologic mesh.

Orbital reconstruction with a partially absorbable mesh (monofilament polypropylene fibre and monofilament poliglecaprone-25): Our experience with 34 patients

Purpose

To evaluate the effectiveness and complications related to the use of a partially absorbable mesh for the reconstruction of orbital floor fractures.

This is a retrospective review of 34 consecutive patients who suffered orbital trauma from August 2007 to March 2013 treated with a partially absorbable mesh for orbital reconstruction. Data collected included gender, age, nationality, cause of injury, date of admission, date of surgery, date of discharge, type of fracture, signs and symptoms such as diplopia, enophthalmos, and sensory disturbance related to the infraorbital nerve, complications before and after surgery, and follow-ups at 1 week, 1 month, 6 months, and after 1 year.

Results

Since January 2007, 34 patients were treated in our department with orbital fractures: 28 males (82.4%) and 6 females (17.6%). The mean age was 31 years (minimum 14, maximum 45). The main causes of trauma were road traffic accidents (20 patients, 58.8%), followed by work-related accidents (9 patients, 26.5%), aggressions (3 patients, 8.8%), and sports (2 patients, 6%). Posttraumatic Diplopia was present in 20 patients (58.8%), and enophthalmos was in 9 (26.5%). The incidence of postoperative diplopia was present in 8 patients (23.5%), which decreased to 1 (2.9%) after one year. Paresthesia due to trauma was first noticed in 8 patients (20.6%) and completely disappeared after 12 months. Post surgical enophthalmos was noticed in 3 patients (7.5%). There was one case of migration of the mesh and one case of adherence in the lower lid. Both required surgery and resolved completely. Time from trauma to surgery was on average 5.5 days (min 0, max 27, SD 5.15), and the number of days before discharge was 3.5 days (min 1, max 16, SD 2.61).

Conclusions

This study describes the results of the first series of orbital floor reconstructions with a partially absorbable mesh (Monofilament polypropylene fibre and monofilament poliglecaprone-25) to date. Although there are a wide variety of materials for treatment, we believe it is a suitable option with an acceptable rate of complications.

Outcomes of bridging versus mesh augmentation in laparoscopic repair of small and medium midline ventral hernias

BACKGROUND

Bridging of the hernia defect in laparoscopic repair (sIPOM) technique does not fully restore the abdominal wall function. Closure of hernia defect in IPOM-plus technique leads to the restoration of abdominal wall function and improved long-term treatment outcomes. Against the expectations, the studies confirm the formation of intraabdominal adhesions to the mesh. Regardless of the above, the search of the proper technique for mesh implantation and fixation is still ongoing. There have also been attempts to identify groups of patients who may still benefit from IPOM procedure.

MATERIALS AND METHODS

Patients with midline abdominal wall hernias up to 10 cm wide were enrolled in the study except for subxiphoid and suprapubic hernias. Between 2011 and 2014 we performed 82 hernia repairs using the laparoscopic technique with Physiomesh. Patients were divided into sIPOM and IPOM-plus groups. The study included 44M and 38F patients aged 27-84 years. After 12-months and again in August 2015 a survey was posted to all patients with questions regarding potential recurrence.

RESULTS

After 12 months, eight patients (20 %) in sIPOM group reported subjectively perceived recurrence and none in IPOM-plus group (p = 0.002). Six patients (14.3 %) in sIPOM group reported suspected recurrence, as compared to three patients (7.1 %) in IPOM-plus group (p = 0.13). These patients were invited for a follow-up physical examination and sonography. Eventually, four cases of hernia recurrence were confirmed in sIPOM group (10 %) and none in IPOM-plus group (p = 0.018). Other patients presented with mesh bulging.

CONCLUSIONS

Laparoscopic ventral hernia repair is generally safe and is associated with the low recurrence rate. Closure of fascial defects before mesh insertion offers better treatment outcomes. Non-closure of fascial defects with only bridging of the hernia defect (sIPOM) causes more frequent recurrence and bulging. As a result, patient satisfaction with treatment is lower, and they are concerned about hernia recurrence.

Standardized measurement of quality of life after incisional hernia repair: a systematic review

BACKGROUND

Recent improvements in incisional hernia repair have led to lower rates of recurrence. As a consequence, increasing attention has been paid to patient-reported outcomes after surgery. However, there is no consensus on how to measure patients' quality of life after incisional hernia repair. The aim of this systematic review was to analyze existing standardized methods to measure quality of life after incisional hernia repair.

DATA SOURCES

A PubMed and Embase search was carried out together with a cross-reference search of eligible papers, giving a total of 26 included studies.

CONCLUSIONS

Different standardized methods for measurement of quality of life after incisional hernia repair are available, but no consensus on the optimal method, timing, or length of follow-up exist. International guidelines could help standardization, enabling better comparison between studies.