The effect of component separation technique on quality of life (QOL) and surgical outcomes in complex open ventral hernia repair (OVHR)

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias

INTRODUCTION

Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown.

METHODS

The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups.

RESULTS

In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013).

CONCLUSIONS

This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.

Surgical Anatomy of Transversus Abdominis Muscle for Transversus Abdominis Release: A CT-Based Study in Three Patient Groups

BACKGROUND

The anatomy of the transversus abdominis muscle and its aponeurosis is important in transversus abdominis release surgery. We studied the CT anatomy of the transversus abdominis muscle medial to the linea semilunaris at different levels in the abdomen and measured the thickness of this muscle.

METHODS

In this retrospective study, we analysed 150 abdominal computed tomography at L1, L3, and L5 vertebral levels corresponding to subxiphoid, umbilical, and suprapubic regions, respectively. The patients were divided into three groups based on age and sex: women aged 15-20 years (nulliparous), women aged 30-60 years (multiparous), and men aged 15-60 years, with each group having 50 patients. We compared the thickness of the TA muscle at the L1 level between men and women and between nulliparous and multiparous women.

RESULTS

Transversus abdominis muscle was consistently present medial to the linea semilunaris at L1 vertebral level in the subxiphoid region (150/150). At the L3 vertebral level in the mid-abdomen, only eight patients had the transversus abdominis muscle there (8/150, 5%). At the L5 vertebral level in the suprapubic region, no patient had the transversus abdominis muscle medial to the linea semilunaris. The mean thickness of the transversus abdominis muscle at the L1 level was 3.4 mm, and at the L3 level, it was 1.6 mm. There was no statistically significant difference in the transversus abdominis muscle thickness between the men and women; however, a significant difference was found between the nulliparous and multiparous women, with thinner TA muscle in later.

CONCLUSION

There is good transversus abdominis muscle bulk medial to the linea semilunaris for doing transversus abdominis muscle division in the upper abdomen. However, as we move towards the mid-abdomen, we have TA aponeurosis or rarely TA muscle of little bulk.

Surgical and Patient-Reported Outcomes of Open Perforator-Preserving Anterior Component Separation for Ventral Hernia Repair

BACKGROUND

 Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair.

METHODS

 A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life.

RESULTS

 Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m2, respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08-0.62), which corresponds to absence or minimal symptoms.

CONCLUSION

 The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality.

Long term outcomes of robotic-assisted abdominal wall reconstruction: a single surgeon experience

INTRODUCTION

Robotic abdominal wall reconstruction (RAWR) is one of the most significant advances in the management of complex abdominal wall hernias. The objective of this study was to evaluate long term outcomes in a cohort of patients that underwent complex RAWR in a single center.

METHODS

This was a longitudinal retrospective review of a cohort of 56 patients who underwent complex RAWR at least 24 months prior by a single surgeon at a tertiary care institution. All patients underwent bilateral retro-rectus release (rRRR) with or without robotic transversus abdominis release (rTAR). Data collected include demographics, hernia details, operative and technical details. The prospective analysis included a post-procedure visit of at least 24 months from the index procedure with a physical examination and quality of life survey using the Carolinas Comfort Scale (CCS). Patients with reported symptoms concerning for hernia recurrence underwent radiographic imaging. Descriptive statistics (mean ± standard deviation or median) were calculated for continuous variables. Chi-square or Fisher's exact test as deemed appropriate for categorical variables, and analysis of variance or the Kruskal-Wallis test for continuous data, were performed among the separate operative groups. A total score for the CCS was calculated and analyzed in accordance with the user guidelines.

RESULTS

One-hundred and-forty patients met the inclusion criteria. Fifty-six patients consented to participate in the study. Mean age was 60.2 years. Mean BMI was 34.0. Ninety percent of patients had at least one comorbidity and 52% of patients were scored ASA 3 or higher. Fifty-nine percent were initial incisional hernias, 19.6% were recurrent incisional hernias and 8.9% were recurrent ventral hernias. The mean defect width was 9 cm for rTAR and 5 cm for rRRR. The mean implanted mesh size was 945.0 cm² for rTAR and 362.5 cm² for rRRR. The mean length of follow-up was 28.1 months. Fifty-seven percent of patients underwent post-op imaging at an average follow-up of 23.5 months. Recurrence rate was 3.6% for all groups. There were no recurrences in patients that underwent solely bilateral rRRR. Two patients (7.7%) that underwent rTAR procedures were found with recurrence. Average time to recurrence was 23 months. Quality of life survey demonstrated an overall CCS score of 6.63 ± 13.95 at 24 months with 12 (21.4%) patients reporting mesh sensation, 20 (35.7%) reporting pain, and 13 (23.2%) reporting movement limitation.

CONCLUSION

Our study contributes to the paucity of literature describing long term outcomes of RAWR. Robotic techniques offer durable repairs with acceptable quality of life metrics.

The outcomes of open anterior component separation versus posterior component separation with transversus abdominis release for complex incisional hernias: a systematic review and meta-analysis

PURPOSE

The main objective was to assess the prevalence of hernia recurrence, wound complications (surgical site infections [SSI], seroma and hematoma) and mortality after anterior component separation (ACS) and posterior component separation via transversus abdominis muscle release (PCSTAR) in patients with complex incisional hernias. The so-called complex IH is a serious medical and societal challenge due to its direct and indirect costs; it is also hampered by the use of different surgical techniques, different type of meshes, and different results heterogeneously reported and interpreted. According to actual data, the best approach seems to be a mesh reinforcement component separation procedure augmented or not with an adjuvant technique (preoperative progressive pneumoperitoneum and/or Botulin toxin type A infiltration).

METHODS

A systematic search of four databases (MEDLINE, PubMed, Web of Science, and Google Scholars) was conducted to identify studies reporting on outcomes of component separation techniques and which were published before December 2021. A systematic review and a meta-analysis of postoperative outcomes were performed.

RESULTS

Nineteen studies including 3412 patients (1709 with ACS and 1703 with PCSTAR) were selected. Pooled hernia recurrence rate after a minimum 1-year follow-up was evaluated at 5.15% (odds ratio [OR] 0.68; 95% confidence interval [CI] 0.5-0.9; p = 0.0175). Pooled surgical site infection rate was 10.6% (OR 1.32; 95% CI 1.06-1.65; p = 0.0119). Seroma and hematoma were estimated at 9.75% (OR 1.93; 95% CI 1.52-2.44; p = 0.0001) and 3.83% (OR 1.81; 95% CI 1.26-2.61; p = 0.0012), respectively. ACS was associated with increased wound morbidity, seroma and hematoma. PCSTAR displayed higher recurrence rate (4.27% vs 6.11%).

CONCLUSIONS

PCSTAR was superior to ACS in terms of wound morbidity, surgical site infections, seroma and hematoma incidence. The procedure should be further evaluated in comparative head-to-head randomized controlled trials.

Endoscopic Anterior Component Separation and Transversus Abdominus Release are not Associated with Increased Wound Morbidity Following Retromuscular Incisional Hernia Repair

INTRODUCTION

Traditional anterior component separation during incisional hernia repair (IHR) is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence (SSO) compared to IHR without component separation (CS).

MATERIAL AND METHOD

This was a retrospective single-center cohort study of patients undergoing open retromuscular IHR comparing patients with or without the use of CS. Retromuscular mesh repair was performed in all patients, and CS was obtained by eACS or TAR. The primary outcome was 90-day incidence of postoperative SSO. Secondary outcomes included length of stay (LOS), 90-day readmission, 90-day reoperation rate and 3-year recurrence rate.

RESULTS

A total of 321 patients underwent retromuscular repair, 168 (52.3%) of whom received either eACS or TAR. The addition of eACS or TAR was associated neither with development of SSO (odds ratio: 1.80, 95% confidence interval: 0.94-3.46, P = 0.077) nor with hernia recurrence (hazard ratio 0.77, 0.26-2.34, P = 0.648). There was no significant difference between the groups regarding the frequencies of 90-day readmission or 90-day reoperation.

CONCLUSION

eACS or TAR as adjuncts to open retromuscular IHR were not associated with increased wound morbidity or hernia recurrence.

Transversus abdominis release (TAR) procedure: a retrospective analysis of an abdominal wall reconstruction group

Complex abdominal wall defects are important conditions with high morbidity, leading to impairment of patients' physical condition and quality of life. In the last decade, the abdominal wall reconstruction paradigm has changed due to the formation of experienced and excellence groups, improving clinical outcomes after surgery. Therefore, our study shows the perspective and outcomes of an abdominal wall reconstruction group (AWRG) in Colombia, focused on the transverse abdominis release (TAR) procedure. A retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent TAR procedures between January 2014-December 2020 were included. Analysis and description of postoperative outcomes (recurrence, surgical site infection (SSI), seroma, hematoma, and re-intervention) were performed. 47 patients underwent TAR procedure. 62% of patients were male. Mean age was 55 ± 13.4 years. Mean BMI was 27.8 ± 4.5 kg/m². Abdominal wall defects were classified with EHS ventral Hernia classification having a W3 hernia in 72% of all defects (Mean gap size of 11.49 cm ± 4.03 cm). Mean CeDAR preoperative risk score was 20.5% ± 14.5%. Preoperative use of BOTOX Therapy (OR 1.0 P 0.00 95% CI 0.3-1.1) or pneumoperitoneum (OR 0.7 P 0.04 95% CI 0.3-0.89) are slightly associated with postoperative hematoma. In terms of hernia relapse, we have 12% of cases; all of them over a year after the surgery. TAR procedure for complex abdominal wall defects under specific clinical conditions including emergency scenarios is viable. Specialized and experienced groups show better postoperative outcomes; further studies are needed to confirm our results.

Morphological alterations of the abdominal wall after open incisional hernia repair with endoscopic anterior and open posterior component separation

PURPOSE

Effects of component separation (CS) on abdominal wall morphology have only been investigated in smaller case series or cadavers. This study aimed to compare abdominal wall alterations following endoscopic anterior CS (EACS) or open transverse abdominis release (TAR).

METHODS

Computed tomography scans were evaluated in patients who had undergone open incisional hernia repair with EACS or TAR. Abdominal wall circumference, lateral abdominal wall muscle thickness, and displacement were compared with (1) preoperative images after bilateral CS and (2) the undivided side postoperatively after unilateral CS.

RESULTS

In total, 105 patients were included. Fifty-five (52%) and 15 (14%) underwent bilateral and unilateral EACS, respectively. Five (5%) and 14 (13%) underwent bilateral and unilateral TAR, respectively. Sixteen (15%) underwent unilateral EACS and contralateral TAR. The external oblique and transverse abdominis muscles were significantly laterally displaced with a mean of 2.74 cm (95% CI 2.29-3.19 cm, P < 0.001) and 0.82 cm (0.07-1.57 cm, P = 0.032) after EACS and TAR, respectively. The combined thickness of the lateral muscles was significantly decreased after EACS (mean decrease 10.5% (5.8-15.6%, P < 0.001)) and insignificantly decreased after TAR (mean decrease 2.6% (- 4.8 to 9.5%, P = 0.50)). The abdominal wall circumference was unchanged after bilateral (mean reduction 0.90 cm (- 0.77 to 2.58 cm), P = 0.29) and unilateral CS (mean increase 0.03 cm (- 1.01 to 1.08 cm), P = 0.95).

CONCLUSION

Postoperative changes in the lateral abdominal wall musculature were different following EACS and open TAR. Either technique seems not to compromise the overall integrity of the lateral abdominal wall.

Health-related quality of life in abdominal wall hernia: let's ask patients what matters to them?

INTRODUCTION

Quality of Life (QoL) is an important consideration in patients with abdominal wall hernia (AWH). What matters to patients and their everyday experience living with AWH may depend on a variety of personal, psychological, social and environmental factors. At present, no study has addressed what is important to this particular group of patients by asking the patients themselves. This study aims to determine QoL from the patient's perspective by examining the lived experience in this patient population.

METHODS

We interviewed 15 patients with AWH until thematic saturation. The patients were purposively sampled from AWH clinic between February 2020 and June 2020 using topic guides and interview schedules. Verbatim interview transcripts were coded and analysed using NVivo12 software and Interpretative Phenomenological Analysis (IPA). We adhered to consolidated criteria for reporting qualitative research (COREQ).

RESULTS

Fifteen participants (8 men and 7 women) of age range 36-85 years, median 65 years, covering all Ventral Hernia Working Group (VHWG) grades. Five superordinate themes were identified each with several subordinate themes, as follows: (1) body image (subthemes-'changes to perceptions of self' and 'fears concerning perceptions of others'). (2) Mental health (subthemes-'emotional responses', 'disruptions to previously solid aspects of identity', 'developing coping strategies'). (3) Symptoms (subthemes-'managing pain', 'freedom of movement', 'restriction and adaptation of function'). (4) Interpersonal relationships (subthemes-'difficulties socially connecting' and 'changes in sexual relations'). (5) Employment (subthemes-'financial pressure', 'return to work issues' and 'costs to family').

CONCLUSION

This is the first phenomenological qualitative study in the field of AWH and presents a rich account of what is important to these patients in terms of QoL. Developed from the patients' own words, the themes are interrelated and should shape our understanding of patients with AWH. This study provides qualitative examples of each theme. This study has identified new themes (body image, interpersonal relationships and employment) that are not incorporated in existing AWH-specific QoL instruments. This is important for surgeons because the study suggests that we are currently not capturing all data relevant to QoL in this specific patient group with current tools. The wider impact of this would be to help counsel patients and support them more holistically through the disease process and it's management. Further research is needed to generate a standardised AWH QoL instrument which incorporates bio-psycho-emotional-social themes important to patients, as identified by patients.

Chronological age does not predict postoperative outcomes following transversus abdominis release (TAR)

BACKGROUND

Transversus abdominis release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TAR is not a low risk operation, particularly in older adults who are disproportionately affected by multiple age-related risk factors. While past studies have suggested that age alone inconsistently predicts patient outcomes, data regarding age's effect on postoperative outcomes and wound complications following a TAR are lacking.

METHODS

Patients who underwent either an open or robotic bilateral TAR from 1/2018 to 9/2020 were eligible for the study. Patients were stratified by age groups (≥ 60 years vs. < 60 years and < 60, 60-70, and ≥ 70) and by both age and operative approach. The rates of key postoperative outcomes and wound morbidity were compared between the various cohorts.

RESULTS

A total of 300 patients were included: 165 patients were ≥ 60 and 135 patients were < 60. Cohorts stratified by age were well-matched for important hernia factors: defect size (p = 0.31), BMI ≥ 30 (p = 0.46), OR time (p = 0.25), percent open TAR (p = 0.42), diabetes (p = 0.45) and history of prior surgical site infection (p = 0.40). The older cohort had significantly higher rates of coronary artery disease, hypertension, and COPD. On univariate analysis, cohorts stratified by age had similar rates of key postoperative and wound complications including in-hospital complications (p = 0.62), length of stay (p = 0.47), readmissions (p = 0.66), and surgical site occurrences (p = 0.68). Additionally, cohorts stratified by both age and operative approach also had similar outcomes. Multivariate analysis showed that chronological age was not independently associated with surgical site occurrences (p = 0.22), readmissions (p = 0.99), in-hospital complications (p = 0.15), or severe complications (p = 0.79).

CONCLUSION

Open and robotic TARs can be safely performed in older adults and chronological age alone is a poor predictor of patient morbidity following TAR. Further investigation of alternative preoperative screening tools that do not rely solely on age are needed to better optimize surgical outcomes in older adults following TAR.

Outcomes of posterior component separation with transversus abdominis release (TAR) in large and other complex ventral hernias: a single-surgeon experience

PURPOSE

Over the last years, great advances in the repair of abdominal wall hernias have dramatically improved patients' outcomes. Especially for large and other complex ventral hernias, the application of component separation techniques has been a landmark in their successful management. The aim of this study is to present our experience with the posterior component separation with transversus abdominis release (TAR) in patients with these demanding ventral hernias.

METHODS

A retrospective analysis of prospectively collected data of all patients who underwent elective ventral hernia repair with TAR between January 2016 and December 2019 was performed. Preoperative, intraoperative, and postoperative data were analyzed.

RESULTS

A total of 125 patients with large and other complex ventral hernias were included in the final analysis. More than 80% of patients had one or more comorbidities. Of all patients, 116 (92.8%) had a history of previous abdominal surgery, 27 (21.6%) had a history of SSI and nine (7.2%) had active fistulas. Postoperatively, SSOs were presented in 11 patients (8.8%), including three cases of SSI. Neither mesh infection occurred, nor mesh excision required. With a mean follow-up of 2.5 years, only one recurrence was observed.

CONCLUSIONS

With a wound complication rate of less than 9% and a recurrence rate of less than 1%, our results show that TAR is a reliable, safe and effective technique for the repair of massive and other complex ventral hernias. The combination of knowledge of the abdominal wall anatomy at a proficient level, proper training, and adoption of a strict prehabilitation program are considered prerequisites for the successful management of such demanding hernias.

Perioperative optimization in complex abdominal wall hernias: Delphi consensus statement

BACKGROUND

The incidence of incisional hernia after major abdominal surgery via a midline laparotomy is 20-41 per cent with short-term follow-up, and over 50 per cent in those surviving an abdominal catastrophe. Abdominal wall reconstruction (AWR) requires complex operations, often involving mesh resection, management of scarred skin, fistula takedown, component separation or flap reconstruction. Patients tend to have more complex conditions, with multiple co-morbidities predisposing them to a vicious cycle of complications and, subsequently, hernia recurrence. Currently there appears to be variance in perioperative practice and minimal guidance globally. The aim of this Delphi consensus was to provide a clear benchmark of care for the preoperative assessment and perioperative optimization of patients undergoing AWR.

METHODS

The Delphi method was used to achieve consensus from invited experts in the field of AWR. Thirty-two hernia surgeons from recognized hernia societies globally took part. The process included two rounds of anonymous web-based voting with response analysis and formal feedback, concluding with a live round of voting followed by discussion at an international conference. Consensus for a strong recommendation was achieved with 80 per cent agreement, and a weak recommendation with 75 per cent agreement.

RESULTS

Consensus was obtained on 52 statements including surgical assessment, preoperative assessment, perioperative optimization, multidisciplinary team and decision-making, and quality-of-life assessment. Forty-six achieved over 80 per cent agreement; 14 statements achieved over 95 per cent agreement.

CONCLUSION

Clear consensus recommendations from a global group of experts in the AWR field are presented in this study. These should be used as a baseline for surgeons and centres managing abdominal wall hernias and performing complex AWR.

Does immunosuppression use increase perioperative wound morbidity in patients undergoing transversus abdominis release?

BACKGROUND

Transversus abdominis release is an effective procedure for complex ventral hernias. As wound complications contribute to hernia recurrences, mitigating risk factors is vitally important for hernia surgeons. Although immunosuppression can impair wound healing, it has inconsistently predicted wound occurrences, and its effect on wound morbidity after a transversus abdominis release is unknown.

METHODS

Patients undergoing either an elective open or robotic bilateral transversus abdominis release with permanent synthetic mesh were retrospectively stratified by perioperative immunosuppression and secondarily by procedure type (open versus robotic) and immunosuppression.

RESULTS

A total of 321 patients were included for analysis. Overall, 63 (19.6%) patients were on chronic immunosuppression, with history of solid-organ transplant being the most common indication (43 patients). Patients stratified by perioperative immunosuppression were well-matched with similar defect size (P = .97), body mass index ≥30 (P = .32), diabetes (P = .09), history of surgical site infection (P = .53), surgical approach (P = .53), and tobacco use history (P = .33). No differences between cohorts were elicited for any wound event when stratified by immunosuppression use. Similarly, no differences were elicited when cohorts were further stratified also by procedure type.

CONCLUSION

Chronic immunosuppression is often viewed as a notable risk factor for wound occurrences after surgery. However, our data suggest immunosuppression may not significantly increase the risk of perioperative wound morbidity follow transversus abdominis release as previously predicted.

Single institute experience with anterior and posterior component separation techniques for large ventral hernias: A retrospective review

BACKGROUND

Component separation techniques have recently gained popularity for the repair of complex ventral hernias. Anterior and posterior component separation techniques offer similar myofascial medialization, with a differing complication profile. The aim of this study is to compare the efficacy, patient morbidity and post-operative complications between anterior component separation (ACST) and transversus abdominis release (TAR) for large ventral hernias.

METHODS

Between December 2017 and September 2019, data was collected and analysed for patients undergoing ACST and TAR, in terms of demographics, peri-operative events, adverse events and hernia recurrence.

RESULTS

25 patients each underwent ACST and TAR during our study period. Mean age was 53.5 and 52.8 years and mean BMI was 31.4 and 29.5 respectively. The mean defect area was 120.8 cm² and 131.9 cm², and average mesh size was 741.8 cm² and 1429.04 cm² respectively in the ACST and TAR groups. Four patients undergoing TAR had intra-operative complications with none in the ACST group. In the ACST group, 8 patients had an SSI, of which 5 patients needed operative intervention, while 3 patients in the TAR group had an SSI, all of whom were managed with bedside procedures. One patient in the ACST group had a recurrence. None of the patients in the TAR group had a recurrence.

CONCLUSIONS

Component separation techniques are gaining popularity in treatment of large ventral hernias. While they have comparable outcomes with respect to recurrence, wound morbidity is more frequent and severe in the ACST group.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG)

AIM

To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients.

METHODS

All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed.

RESULTS

During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m². ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004).

CONCLUSION

CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

The incisional hernia epidemic: evaluation of outcomes, recurrence, and expenses using the healthcare cost and utilization project (HCUP) datasets

BACKGROUND

Incisional hernias (IH) following abdominal surgery persist as morbid, costly, and multi-disciplinary surgical challenges. Using longitudinal, multi-state, administrative claims data (HCUP State Inpatient Databases (SID)); (HCUP State Ambulatory Surgery and Services Databases (SASD)), we aimed to characterize the epidemiology, outcomes, recurrence, and costs of IH.

STUDY DESIGN

529,108 patients undergoing abdominal surgery in 2010 across six specialties (colorectal, general/bariatric, hepatobiliary, obstetrics/gynecology, urology, and vascular) were identified within inpatient and ambulatory databases for Florida (FL), Iowa (IA), Nebraska (NE), New York (NY), and Utah (UT). IH repairs, complications, and expenditures were assessed through 2014. Predictive regression modeling was validated using a training set of 1000 bootstrapped repetitions.

RESULTS

16,169 (3.1%) patients developed hernias requiring repair (4.3-year mean follow-up), 3176 (20%) underwent recurrent repair, and 731 (23%) underwent re-recurrent repair. Patients with IH had increased readmissions (6.6 vs. 2.4), morbidity (39 vs. 8% surgical and 22 vs. 7% medical), and costs ($46,000 vs. $25,000) when compared to patients without IH (p < 0.001). IH expenditures totaled $875 million: initial ($687 million), recurrent ($155 million), and re-recurrent hernias ($33 million). IH predominated in colorectal (10%), hepatobiliary (8%), and vascular (5%) procedures. Of 31 significant independent IH risk factors (p < 0.001), obesity, age, smoking, open surgery, and prior surgery were pervasive across surgical specialties.

CONCLUSION

IH represents an unremitting surgical epidemic associated with considerable morbidity, costs, and features consistent with a chronic disease state. We define critical pervasive risk factors (obesity, age, smoking open surgery, and prior surgery) independently associated with IH across surgical disciplines. With failed repairs, subsequent success becomes less likely, increasing morbidity and costs-underscoring the critical importance of optimal treatment and prevention.

Measuring quality of life in patients with abdominal wall hernias: a systematic review of available tools

INTRODUCTION

Abdominal wall herniation (AWH) is an increasing problem for patients, surgeons, and healthcare providers. Surgical-site specific outcomes, such as infection, recurrence, and mesh explantation, are improving; however, successful repair still exposes the patient to what is often a complex major operation aimed at improving quality of life. Quality-of-life (QOL) outcomes, such as aesthetics, pain, and physical and emotional functioning, are less often and less well reported. We reviewed QOL tools currently available to evaluate their suitability.

METHODS

A systematic review of the literature in compliance with PRISMA guidelines was performed between 1st January 1990 and 1st May 2019. English language studies using validated quality-of-life assessment tool, whereby outcomes using this tool could be assessed were included.

RESULTS

Heterogeneity in the QOL tool used for reporting outcome was evident throughout the articles reviewed. AWH disease-specific tools, hernia-specific tools, and generic tools were used throughout the literature with no obviously preferred or dominant method identified.

CONCLUSION

Despite increasing acknowledgement of the need to evaluate QOL in patients with AWH, no tool has become dominant in this field. Assessment, therefore, of the impact of certain interventions or techniques on quality of life remains difficult and will continue to do so until an adequate standardised outcome measurement tool is available.

Ventral Hernia Management in Obese Patients

Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.

Early drain removal does not increase the rate of surgical site infections following an open transversus abdominis release

PURPOSE

Intraoperative drain placement during an open transversus abdominis release (TAR) is common practice. However, evidence detailing the optimal timing of drain removal is lacking. Surgical dogma teaches that drains should remain in place until output is minimal. This practice increases the risk of drain-associated complications (infection, pain, and skin irritation) and prolongs the burden of surgical drain maintenance. The objective of this study is to review infectious outcomes following TAR with early or late drain removal.

METHODS

Patients who underwent an open bilateral TAR from 1/2018 to 1/2020 were eligible for the study. Prior to 2019, one of the two intraoperative drains was left in place at discharge. In 2019, clinical practice shifted to remove both drains at hospital discharge irrespective of output. The rate of infectious morbidity was compared between the two cohorts.

RESULTS

A total of 184 patients were included: 89 late and 95 early drain removal. No differences in wound complications existed between the two cohorts: surgical site occurrence (SSO): 21.3% vs. 18.9% (p = 0.68); surgical site infection (SSI): 14.6% vs. 10.5% (p = 0.40); abscess: 8.9% vs. 4.2% (p = 0.20); seroma: 6.7% vs. 10.5% (p = 0.36); cellulitis: 14.6% vs. 8.4% (p = 0.19%); or SSO requiring procedural intervention (SSOPI): 5.6% vs. 5.2% (p = 0.92). Rates of antibiotic prescription and 30-day readmission were also similar (p = 0.69 and p = 0.89).

CONCLUSIONS

Early removal of abdominal wall surgical drains at discharge irrespective of drain output does not increase the prevalence of infectious morbidity following TAR. It is likely safe to remove all drains at discharge regardless of drain output.

The "Corset Repair" for Complex Hernia: A Proof-of-concept Report of an Innovative Approach

Incisional hernias, especially those below the arcuate line, pose a unique challenge to reconstructive surgeons, as no consensus exists for repair strategy. An innovative approach is presented and illustrated. The “corset repair” involves placing an onlay mesh partially beneath released bilateral external obliques. A detailed technical review is provided to illustrate the benefits of this technique particularly in large defects and in hernia after abdominal flap harvest. Hernia recurrence and surgical site occurrence rates were reviewed and analyzed for a cohort of corset repair patients between December 2016 and January 2020. Twenty patients were included. All defects were successfully closed. Zero patients experienced hernia recurrence. Eight patients (40%) had a surgical site occurrence, of which 5 (63%) were either observed or managed non-operatively. Two of the surgical site occurrences were deep surgical site infections: 1 required surgical intervention for suspected mesh infection and the other did not. One patient (5%) developed hematoma 23 months post-operatively. The “corset repair” technique represents a modification to a classic technique for hernia repair. It is feasible and may be advantageous especially for large or challenging repairs below the arcuate line. It has promising results on early follow-up, and further research is needed to evaluate long-term efficacy.

Beyond the Hernia Repair: A Review of the Insurance Coverage of Critical Adjuncts in Abdominal Wall Reconstruction

The prevalence of complex abdominal wall defects continues to rise, which necessitates increasingly sophisticated medical and surgical management. Insurance coverage for reconstructive surgery varies due to differing interpretations of medical necessity. The authors sought to characterize the current insurance landscape for a subset of key adjunctive procedures in abdominal wall reconstruction, including component separation and simultaneous ventral hernia repair with panniculectomy (SVHR-P) or abdominoplasty (SVHR-A), and synthesize a set of reporting recommendations based on insurer criteria.

Methods

Insurance companies were selected based on their national and state market share. Preauthorization criteria, preauthorization lists, and medical/clinical policies by each company for component separation, SVRH-P, and SVRH-A were examined. Coverage criteria were abstracted and analyzed.

Results

Fifty insurance companies were included in the study. Only 1 company had clear approval criteria for component separation, while 38 cover it on a case-by-case basis. Four companies had clear approval policies for SVHR-P, 4 cover them on an individual case basis, and 28 flatly do not cover SVHR-P. Similarly, 3 companies had clear approval policies for SVHR-A, 6 cover them case by case, and 33 do not cover SVHR-A.

Conclusions

Component separation and soft tissue contouring are important adjunctive AWR procedures with efficacy supported by peer-reviewed literature. The variability in SVHR-P and SVHR-A coverage likely decreases access to these procedures even when there are established medical indications. The authors recommend standardization of coverage criteria for component separation, given that differing interpretations of medical necessity increase the likelihood of insurance denials.

INCISIONAL HERNIOPLASTY TECHNIQUES: ANALYSIS AFTER OPEN BARIATRIC SURGERY

BACKGROUND

Rives-Stoppa retromuscular technique: A) polypropylene mesh fixed on the posterior rectus sheath; B) rectus abdominal muscle; C) anterior rectus sheath being sutured. The best technique for incisional hernioplasty has not been established yet. One of the difficulties to compare these techniques is heterogeneity in the profile of the patients evaluated.

AIM

To analyze the results of three techniques for incisional hernioplasty after open bariatric surgery.

METHOD

Patients who underwent incisional hernioplasty were divided into three groups: onlay technique, simple suture and retromuscular technique. Results and quality of life after repair using Carolina's Comfort Scale were evaluated through analysis of medical records, telephone contact and elective appointments.

RESULTS

363 surgical reports were analyzed and 263 were included: onlay technique (n=89), simple suture (n=100), retromuscular technique (n=74). The epidemiological profile of patients was similar between groups. The onlay technique showed higher seroma rates (28.89%) and used a surgical drain more frequently (55.56%). The simple suture technique required longer hospital stay (2.86 days). The quality of life score was worse for the retromuscular technique (8.43) in relation to the onlay technique (4.7) and the simple suture (2.34), especially because of complaints of chronic pain. There was no difference in short-term recurrence.

CONCLUSION

The retromuscular technique showed a worse quality of life than the other techniques in a homogeneous group of patients. The three groups showed no difference in terms of short-term hernia recurrence.

Short- to Midterm Results After Posterior Component Separation with Transversus Abdominis Release: Initial Experience from India

PURPOSE

Posterior component separation with transversus abdominis release is a new procedure and is quickly gaining popularity. It has shown promising results in terms of low recurrence rates for large and complex hernias. However, there are very little Indian data available on this to date. The purpose of this study was to assess the outcomes of the technique at three centers in India.

METHODS

This was a retrospective analysis of the prospectively collected data. Patients with a minimum follow-up of 3 months who underwent open or minimal access posterior component separation were included.

RESULTS

A total of 72 patients (open = 44, minimal access = 25, and hybrid = 3) were included in the analysis. At a follow-up ranging from 3 months to 35 months, there were two recurrences (2.78%). Surgical site occurrences were seen in 23/72 (31.9%), and surgical site infection was seen in 7/72 (9.7%). Surgical site occurrence requiring procedural intervention was 3/72 (4.2%). There were two (2.78%) mortalities in the open group due to myocardial infarction.

CONCLUSION

Posterior component separation with transversus abdominis release may have advantages in terms of low recurrence in large hernias in the Indian population and can be used in carefully selected patients.

An early experience with transversus abdominis release for complex ventral hernias: a retrospective review of 100 cases

BACKGROUND

Transversus abdominis release (TAR) is a relatively recent surgical technique for ventral hernia repair which allows placement of a large prosthesis in the retro-muscular plane with considerable myofascial medialization. A retrospective review of 100 cases who underwent TAR for complex ventral hernias was performed to evaluate the safety and efficacy of TAR in a series of large ventral hernias.

METHODS

Between March 2016 and May 2019, 100 consecutive patients who underwent open TAR were identified from our prospectively maintained database. A retrospective review was performed to analyze patient demographics, peri-operative events, adverse outcomes and recurrence.

RESULTS

12 primary and 88 incisional hernia cases underwent TAR with prosthetic mesh repair during the study period. Mean age was 52.5 years, mean BMI was 30.87 kgs/m², mean ASA class 1.95. In our series, 41% were diabetic, 11% had COPD. All patients underwent preoperative CT scans. The mean defect was 140.18 cm². Average mesh area was 1344 cm². Average blood loss was 245 mL. Defects were bridged in 19% cases despite bilateral component separation. Readmission rate at 1 month was 3%, for wound complications. We recorded 9 surgical site infections, 17 surgical site occurrences, 10 of which needed procedural interventions. We recorded no recurrences at a mean follow-up duration of 20.2 months.

CONCLUSIONS

Our early results with TAR are encouraging. We have demonstrated that the repair allows anatomical reconstruction with a large sublay mesh while inflicting minimal morbidity. TAR can be a valuable tool in complex ventral hernia repair.

Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

Many experts in abdominal wall reconstruction believe that the combination of simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is contraindicated. We performed ipsilateral endoscopic ACS and either endoscopic or open PCS-transversus abdominis release (TAR) in 5 fresh cadaver models. The full length of the semilunar line and the lateral abdominal wall remained well reinforced by 2 complete layers, comprising the internal oblique (IO) and TA muscles and their investing fasciae. Myofascial releases occurred 4 cm (median) apart. Additionally, we reviewed computed tomography images at 1 month and 1 year after PCS-TAR in 17 patients (30 PCS-TARs). Lateral displacement of the TA relative to the rectus abdominis (RA) was significant only at the superior mesenteric artery level, where it was <1 cm (median). Muscle mass changed minimally over time. Several studies showed that abdominal wall reconstruction after PCS-TAR results in compensatory muscular hypertrophy of the RA, external oblique (EO), and IO muscles and provides better quality of life and improved core physiology. These changes did not occur when the midline was not restored. Theoretically, endoscopic ACS-EO may be added to PCS-TAR to avoid partially bridged mesh repair in patients in whom complete midline restoration is impossible via PCS-TAR alone. Nevertheless, we advise most surgeons to perform a small-bridged repair instead of risking increased morbidity by attempting a highly complicated procedure.

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.

Clinical and Functional Outcome After Abdominal Wall Incisional Hernia Repair: Evaluation of Quality-of-Life Improvement and Comparison of Assessment Scales

BACKGROUND

Hernias severely impact patient quality of life (QoL), and 80% of patients need surgical operation. The primary outcome of the study is to assess improvements in balance, posture and deambulation after abdominal hernia repair. Moreover, the study investigated the improvement in the postoperative QoL.

METHODS

Patients operated at the Policlinico "Paolo Giaccone" at Palermo University Hospital between June 2015 and June 2017 were identified in a prospective database. The functional outcome measures and QoL assessment scales used were numeric rating scale for pain, performance-oriented mobility assessment (POMA) scale, Quebec back pain disability scale, center of gravity (barycenter) variation evaluation, Short-Form (36) Health Survey (SF-36 test), sit-up test and Activities Assessment Scale (AAS). The timepoints at which the parameters listed were assessed for the study were 1 week before the surgical operation and 6 months later.

RESULTS

The POMA scale showed a significant improvement, with an overall preoperative score of (mean; SD) 18.80 ± 2.17 and a postoperative score of 23.56 ± 2.24 with a p < 0.003. The improvement of the barycenter was significant with p = 0.03 and 0.01 for the right and left inferior limbs, respectively. Finally, common daily activities reported by the SF-36 test and by the AAS were significantly improved with a reported p of ≤0.04 for 5 of eight items and ≤0.002 for all items, respectively.

CONCLUSIONS

The improvement in such physical measures proves the importance of abdominal wall restoration to recover functional activity in the muscle-skeletal complex balance, gait and movement performance.