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Ghanem OM, Orenstein S, Lloyd SJA, Andalib A, Race A, Burt HA, Husain F, Goldblatt M, Kroh M. Management of abdominal wall hernias in patients with severe obesity. Surg Endosc 2023; 37:6619-6626. [PMID: 37488442 DOI: 10.1007/s00464-023-10312-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023]
Abstract
Obesity is a risk factor for abdominal wall hernia development and hernia recurrence. The management of these two pathologies is complex and often entwined. Bariatric and ventral hernia surgery require careful consideration of physiologic and technical components for optimal outcomes. In this review, a multidisciplinary group of Society of American Gastrointestinal and Endoscopic Surgeons' bariatric and hernia surgeons present the various weight loss modalities available for the pre-operative optimization of patients with severe obesity and concurrent hernias. The group also details the technical aspects of managing abdominal wall defects during weight loss procedures and suggests the optimal timing of definitive hernia repair after bariatric surgery. Since level one evidence is not available on some of the topics covered by this review, expert opinion was implemented in some instances. Additional high-quality research in this area will allow for better recommendations and therefore treatment strategies for these complex patients.
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Affiliation(s)
- Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Sean Orenstein
- Division of Gastrointestinal and General Surgery, Oregon Health and Science University, Portland, OR, USA
| | | | - Amin Andalib
- Department of Surgery, McGill University, Montreal, QC, USA
| | - Alice Race
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Holly Ann Burt
- Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Los Angeles, CA, USA
| | - Farah Husain
- College of Medicine, University of Arizona, Phoenix, AZ, USA
| | - Matthew Goldblatt
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew Kroh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
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Handzel RM, Huckaby LV, Dadashzadeh ER, Silver D, Rieser C, Sivagnanalingam U, Rosengart MR, van der Windt DJ. Sex, race, and socioeconomic distinctions in incisional hernia management. Am J Surg 2023; 226:202-206. [PMID: 37032236 DOI: 10.1016/j.amjsurg.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/16/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND We sought to explore the impact of sex, race, and insurance status on operative management of incisional hernias. METHODS A retrospective cohort study was conducted to explore adult patients diagnosed with an incisional hernia. Adjusted odds for non-operative versus operative management and time to repair were queried. RESULTS Of the 29,475 patients with an incisional hernia, 20,767 (70.5%) underwent non-operative management. In relation to private insurance, Medicaid (aOR 1.40, 95% CI 1.27-1.54), Medicare (aOR 1.53, 95% CI 1.42-1.65), and uninsured status (aOR 1.99, 95% CI 1.71-2.36) were independently associated with non-operative management. African American race (aOR 1.30, 95% CI 1.17-1.47) was associated with non-operative management while female sex (aOR 0.81, 95% CI 0.77-0.86) was predictive of elective repair. For patients who underwent elective repair, both Medicare (aOR 1.40, 95% CI 1.18-1.66) and Medicaid (aOR 1.49, 95% CI 1.29-1.71) insurance, but not race, were predictive of delayed repair (>90 days after diagnosis). CONCLUSIONS Sex, race, and insurance status influence incisional hernia management. Development of evidence-based management guidelines may help to ensure equitable care.
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Affiliation(s)
- Robert M Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Esmaeel R Dadashzadeh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Silver
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline Rieser
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Pittsburgh Surgical Outcomes Research Center (PittSORCe), University of Pittsburgh, Pittsburgh, PA, USA
| | - Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Can a free weight management program "move the needle" for obese patients preparing for hernia surgery?: outcomes of a novel pilot program. Hernia 2022; 26:1259-1265. [PMID: 35676471 DOI: 10.1007/s10029-022-02625-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/23/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE Obesity is known to result in increased morbidity and risk of hernia recurrence after ventral hernia repair; however, many patients lack the resources to pursue guided weight loss. We sought to evaluate the effectiveness of a free Weight Management Navigator (WMN) program on preoperative weight loss for patients with Class 2 or 3 obesity and complex ventral hernias seeking surgical repair. METHODS From September 2019 and December 2020, all patients with BMI ≥ 35 kg/m2 and ventral hernias seeking surgical care were identified in outpatient clinics at a high-volume hernia center and were offered participation in a free WMN program by the attending surgeon. Descriptive analysis was performed to analyze participation in the program and average weight loss during study period. RESULTS One hundred ninety one patients were identified. Most patients declined to participate in a weight loss program, were unable to be reached, or did not respond to the WMN (58.1%). Eighty patients enrolled in a WMN program, forty-four of which were lost to follow-up (55%). Seventeen patients underwent hernia repair, nine of which were enrolled in a WMN program. Mean weight loss for those enrolled in a program was 5.97 kg compared to 1.8 kg for those who did not participate (p = 0.01). CONCLUSION Enrollment in weight loss programs was low despite encouragement from surgeons, free programs, and accessible platforms. Participation in the WMN correlated with more successful weight loss. Our findings suggest that inability to lose weight may be multifactorial. Further study should be devoted to determining other common barriers to weight loss.
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Rossi FMB, Moreno R, Druziani AL, Perez MM, Possari E, Ferreira Da-Silva RB, Rossi M. INCISIONAL HERNIA AFTER BARIATRIC SURGERY: ONLY THE PHYSICAL EXAMINATION IS ENOUGH? ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1673. [PMID: 36102484 PMCID: PMC9462862 DOI: 10.1590/0102-672020220002e1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/05/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND: Incisional hernia is characterized by a bulging of the abdominal wall caused by the prolapse of intracavitary structures, such as a segment of the small intestine, through the trocar orifice. Ultrasonography and physical examination are used in the diagnosis of incisional hernia. AIMS: This study aimed to evaluate the difference between physical examination and abdominal ultrasonography at the diagnosis of incisional hernia in patients who underwent laparoscopic bariatric surgery. METHODS: A total of 123 patients who underwent Roux-en-Y gastric bypass type bariatric surgery performed by laparoscopy were analyzed for the presence or absence of hernia by physical and ultrasonography examination at each trocar incision site. RESULTS: In our results, a total of 7 hernias were detected by physical examination, while ultrasonography detected a total of 56 hernias in at least one of the incision sites. Lin's concordance analysis showed that the tests are not concordant. The association between body mass index and hernia detection (p=0.04 for physical examination and p=0.052 for ultrasonography) was observed. Ultrasonography detected more incisional hernias in 10-mm or larger trocars than in 5-mm trocars (p<0.0001, p<0.05). No differences were noted among the trocar types that were used. CONCLUSIONS: Abdominal ultrasonography showed to have a higher accuracy than physical examination, resulting in a substantial increase in incisional hernia detection at the trocar sites.
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Griffin SB, Palmer MA, Strodl E, Lai R, Burstow MJ, Ross LJ. Elective Surgery in Adult Patients with Excess Weight: Can Preoperative Dietary Interventions Improve Surgical Outcomes? A Systematic Review. Nutrients 2021; 13:3775. [PMID: 34836028 PMCID: PMC8623302 DOI: 10.3390/nu13113775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 12/12/2022] Open
Abstract
This systematic review summarises the literature regarding the impact of preoperative dietary interventions on non-bariatric surgery outcomes for patients with excess weight/obesity, a known risk factor for poor surgical outcomes. Four electronic databases were searched for non-bariatric surgery studies that evaluated the surgical outcomes of a preoperative diet that focused on weight/fat loss or improvement of liver steatosis. Meta-analysis was unfeasible due to the extreme heterogeneity of variables. Fourteen studies, including five randomised controlled trials, were selected. Laparoscopic cholecystectomy, hernia repair, and liver resection were most studied. Diet-induced weight loss ranged from 1.4 kg to 25 kg. Preoperative very low calorie diet (≤800 kcal) or low calorie diet (≤900 kcal) for one to three weeks resulted in: reduction in blood loss for two liver resection and one gastrectomy study (-27 to -411 mL, p < 0.05), and for laparoscopic cholecystectomy, reduction of six minutes in operating time (p < 0.05) and reduced difficulty of aspects of procedure (p < 0.05). There was no difference in length of stay (n = 7 studies). Preoperative ≤ 900 kcal diets for one to three weeks could improve surgical outcomes for laparoscopic cholecystectomy, liver resection, and gastrectomy. Multiple randomised controlled trials with common surgical outcomes are required to establish impact on other surgeries.
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Affiliation(s)
- Sally B. Griffin
- Department of Nutrition & Dietetics, Logan Hospital, Meadowbrook, QLD 4131, Australia; (M.A.P.); (R.L.)
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, QLD 4059, Australia;
| | - Michelle A. Palmer
- Department of Nutrition & Dietetics, Logan Hospital, Meadowbrook, QLD 4131, Australia; (M.A.P.); (R.L.)
- School of Allied Health Sciences, Griffith University, Gold Coast, QLD 4215, Australia
| | - Esben Strodl
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, QLD 4059, Australia;
| | - Rainbow Lai
- Department of Nutrition & Dietetics, Logan Hospital, Meadowbrook, QLD 4131, Australia; (M.A.P.); (R.L.)
| | - Matthew J. Burstow
- Division of Surgery, Logan Hospital, Meadowbrook, QLD 4131, Australia;
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia
| | - Lynda J. Ross
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, QLD 4059, Australia;
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Abstract
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.
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Abstract
INTRODUCTION Patients undergoing complex ventral hernia repair (VHR) often present with significant medical comorbidities, the most prevalent of which is obesity. Although recent advancements in abdominal wall reconstruction techniques have provided the general hernia patient population with markedly improved recurrence and postoperative complication rates, many patients have been precluded from these procedures owing to excessive body mass index (BMI). In this study, we investigate the viability of complex ventral hernia repair with epigastric artery perforator sparing skin incisions, component separation, and wide-spanning retrorectus mesh reinforcement for patients with BMI of greater than or equal to 40 kg/m(2) (class III obesity). METHODS A single surgeon retrospective review of our prospectively maintained database was performed. We restricted this data to class III morbidly obese patients undergoing open VHR with component muscle separation and wide-spanning mesh reinforcement. RESULTS Between 2010 and 2017, 131 patients met the inclusion criteria for our study. The mean patient BMI was 46.7 kg/m(2). Operative wounds were categorized according to the National Healthcare Safety Network Wound Class Definitions. There was no statistically significant association between wound class and postoperative complication rates. After our implementation of epigastric artery perforator sparing skin incisions in 2013, significantly less wound breakdown was observed (26.3%) as opposed to before (49.0%) (P < 0.01). Furthermore, significantly less cases required return to the operating room after this technique was implemented (31.3%) as compared with before (60.8%) (P < 0.001). Postoperatively, 28 patients developed an infection requiring antibiotic treatment (21.4%), and the overall hernia recurrence rate was 5.3%. Three patients expired. CONCLUSIONS Complex VHR with abdominal wall reconstruction may be a viable option for class III morbidly obese patients. Preliminary data suggest that implementation of epigastric artery perforator sparing skin incisions may reduce the risk of postoperative wound complications, and we have demonstrated hernia recurrence and wound complications comparable with those seen in the general population.
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American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis 2018; 14:1221-1232. [DOI: 10.1016/j.soard.2018.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/05/2018] [Indexed: 02/02/2023]
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Risk factors for the development of flank hernias and bulges following surgical flank approaches to the kidney in adults. Arab J Urol 2018; 16:453-459. [PMID: 30534447 PMCID: PMC6277261 DOI: 10.1016/j.aju.2018.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 04/23/2018] [Accepted: 06/03/2018] [Indexed: 12/22/2022] Open
Abstract
Objectives To evaluate the incidence and risk factors for the development of flank incisional hernias or bulges following surgical flank approaches to the kidney. Patients and methods In all, 100 consecutive adult patients who underwent variable renal surgeries via flank approaches were included in this prospective study. The incidence and risk factors for flank hernias and bulges were studied at 1- and 6-months postoperatively. Results At 6 months postoperatively, the incidence of flank bulge was 14% and for lumbar hernia was 10%. The univariate analysis showed 13 significant factors to be associated with the occurrence of a flank bulge or hernia following flank incisions. When the significant risk factors in the univariate analysis were studied by multivariate analysis, using a logistic regression analysis, four independent risk factors were identified. These were: body mass index (BMI) ≥26.3 kg/m2 (P = 0.04), the use of a self-retaining retractor during surgery (P = 0.02), not preserving or identifying the neurovascular bundle (NVB) during surgery (P = 0.028), and postoperative abdominal distention (P = 0.001). Moreover, all cases included in our study who underwent en masse wound closure, developed surgical wound infection or who had constipation developed postoperative flank bulge or hernia. Conclusion High BMI, the use of self-retaining retractor, not identifying or preserving the NVB, postoperative abdominal distention, en masse wound closure, surgical wound infection, and constipation are significant risk factors associated with postoperative flank hernia and bulge.
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Rossi LF, Trindade MRM, D Acampora AJ, Meurer L. PERITONEAL ADHESIONS TYPE I, III AND TOTAL COLLAGEN ON POLYPROPYLENE AND COATED POLYPROPYLENE MESHES: EXPERIMENTAL STUDY IN RATS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 30:77-82. [PMID: 29257839 PMCID: PMC5543782 DOI: 10.1590/0102-6720201700020001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/07/2017] [Indexed: 12/20/2022]
Abstract
Background: Hernia correction is a routinely performed treatment in surgical practice. The improvement of the operative technique and available materials certainly has been a great benefit to the quality of surgical results. The insertion of prostheses for hernia correction is well-founded in the literature, and has become the standard of treatment when this type of disease is discussed. Aim: To evaluate two available prostheses: the polypropylene and polypropylene coated ones in an experimental model. Methods: Seven prostheses of each kind were inserted into Wistar rats (Ratus norvegicus albinus) in the anterior abdominal wall of the animal in direct contact with the viscera. After 90 days follow-up were analyzed the intra-abdominal adhesions, and also performed immunohistochemical evaluation and videomorphometry of the total, type I and type III collagen. Histological analysis was also performed with hematoxylin-eosin to evaluate cell types present in each mesh. Results: At 90 days the adhesions were not different among the groups (p=0.335). Total collagen likewise was not statistically different (p=0.810). Statistically there was more type III collagen in the coated polypropylene group (p=0.039) while type I was not different among the prostheses (p=0.050). The lymphocytes were statistically more present in the polypropylene group (p=0.041). Conclusion: The coated prosthesis was not different from the polypropylene one regarding the adhesion. Total and type I collagen were not different among the groups, while type III collagen was more present on the coated mesh. There was a greater number of lymphocytes on the polypropylene mesh.
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Affiliation(s)
- Lucas Félix Rossi
- Center for Experimental Research, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Manoel Roberto Maciel Trindade
- Center for Experimental Research, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Armando José D Acampora
- Center for Experimental Research, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Luise Meurer
- Center for Experimental Research, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Sun BJ, Valdez D, Duong D, Gupta R, Smith BR. Evaluation of Preoperative Weight Loss for Elective Hernia Repair in the Veteran Population. Am Surg 2017. [DOI: 10.1177/000313481708301020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The safety and efficacy of preoperative weight loss before elective nonbariatric surgery is controversial. We evaluated the effect of planned surgical delay for a preoperative weight loss trial in hernia repairs. Four hundred and fourteen patients undergoing elective hernia repair between July 2008 and May 2012 at a Level 1B VA Medical Center were identified. Included patients were divided into two groups: those who underwent immediate hernia repair (nontrial) and those who underwent weight loss trial before hernia repair (TRIAL). Twenty-two patients were categorized in the TRIAL group, and 392 in nontrial. Time from surgical evaluation to operation was longer in the TRIAL vs nontrial group (226 days vs 113 days, P = 0.001). Outcome measures were similar between groups. Net change in body mass index (BMI) was -2.2 per cent in TRIAL vs -0.86 per cent in nontrial patients (P = 0.440). Of the TRIAL patients, ten obtained a poor result (<3% decreased BMI), nine a moderate result (3–10% decreased BMI), and three a good result (>10% decreased BMI). Weight loss trials in elective hernia patients appear to be safe, although they result in significant delay to surgery and confer no difference in postoperative outcomes. Thus, efficacy of preoperative weight loss trials may be limited.
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Affiliation(s)
- Beatrice J. Sun
- Department of Surgery, Veteran Affairs Long Beach Healthcare System, Long Beach, California
| | - David Valdez
- Department of Surgery, Veteran Affairs Long Beach Healthcare System, Long Beach, California
| | - Dao Duong
- Department of Surgery, Veteran Affairs Long Beach Healthcare System, Long Beach, California
| | - Ryan Gupta
- Department of Surgery, Veteran Affairs Long Beach Healthcare System, Long Beach, California
| | - Brian R. Smith
- Department of Surgery, Veteran Affairs Long Beach Healthcare System, Long Beach, California
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The Impact of Body Mass Index on Abdominal Wall Reconstruction Outcomes: A Comparative Study. Plast Reconstr Surg 2017; 139:1234-1244. [PMID: 28445378 DOI: 10.1097/prs.0000000000003264] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Obesity and higher body mass index may be associated with higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall reconstruction. The authors hypothesized that higher body mass indexes result in higher rates of postoperative wound healing complications but similar rates of hernia recurrence in abdominal wall reconstruction patients. METHODS The authors included 511 consecutive patients who underwent abdominal wall reconstruction with underlay mesh. Patients were divided into three groups on the basis of preoperative body mass index: less than 30 kg/m (nonobese), 30 to 34.9 kg/m (class I obesity), and 35 kg/m or greater (class II/III obesity). The authors compared postoperative outcomes among these groups. RESULTS Class I and class II/III obesity patients had higher surgical-site occurrence rates than nonobese patients (26.4 percent versus 14.9 percent, p = 0.006; and 36.8 percent versus 14.9 percent, p < 0.001, respectively) and higher overall complication rates (37.9 percent versus 24.7 percent, p = 0.007; and 43.4 percent versus 24.7 percent, p < 0.001, respectively). Similarly, obese patients had significantly higher skin dehiscence (19.3 percent versus 7.2 percent, p < 0.001; and 26.5 percent versus 7.2 percent, p < 0.001, respectively) and fat necrosis rates (10.0 percent versus 2.1 percent, p = 0.001; and 11.8 percent versus 2.1 percent, p < 0.001, respectively) than nonobese patients. Obesity class II/III patients had higher infection and seroma rates than nonobese patients (9.6 percent versus 4.3 percent, p = 0.041; and 8.1 percent versus 2.1 percent, p = 0.006, respectively). However, class I and class II/III obesity patients experienced hernia recurrence rates (11.4 percent versus 7.7 percent, p = 0.204; and 10.3 percent versus 7.7 percent, p = 0.381, respectively) and freedom from hernia recurrence (overall log-rank, p = 0.41) similar to those of nonobese patients. CONCLUSION Hernia recurrence rates do not appear to be affected by obesity on long-term follow-up in abdominal wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Impact of obesity on postoperative 30-day outcomes in emergent open ventral hernia repairs. Am J Surg 2016; 212:1068-1075. [DOI: 10.1016/j.amjsurg.2016.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 09/07/2016] [Accepted: 09/10/2016] [Indexed: 11/22/2022]
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Pernar LIM, Pernar CH, Dieffenbach BV, Brooks DC, Smink DS, Tavakkoli A. What is the BMI threshold for open ventral hernia repair? Surg Endosc 2016; 31:1311-1317. [DOI: 10.1007/s00464-016-5113-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/11/2016] [Indexed: 12/20/2022]
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Holihan JL, Alawadi ZM, Harris JW, Harvin J, Shah SK, Goodenough CJ, Kao LS, Liang MK, Roth JS, Walker PA, Ko TC. Ventral hernia: Patient selection, treatment, and management. Curr Probl Surg 2016; 53:307-54. [DOI: 10.1067/j.cpsurg.2016.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/14/2016] [Indexed: 12/14/2022]
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A Multidisciplinary Approach to Medical Weight Loss Prior to Complex Abdominal Wall Reconstruction: Is it Feasible? J Gastrointest Surg 2015; 19:1399-406. [PMID: 26001369 DOI: 10.1007/s11605-015-2856-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/08/2015] [Indexed: 01/31/2023]
Abstract
Obesity is a major risk factor for perioperative morbidity, especially for patients undergoing complex incisional hernia repair. The feasibility and effectiveness of medical weight loss programs prior to complex abdominal wall reconstruction have not been well characterized. Here, we report our experience collaborating with a medical weight loss specialist utilizing a protein sparing modified fast in order to optimize weight loss prior to complex abdominal wall reconstruction. Morbidly obese patients (body mass index (BMI) > 35 kg/m(2)) evaluated by our medical weight loss specialist prior to complex ventral hernia repair were identified within our prospective database. Our primary outcome measure was the amount of weight lost prior to surgical intervention. Our secondary outcome measure was to determine the maintenance of weight loss during long-term follow-up after the surgical intervention. A total of 25 patients with a BMI > 35 kg/m(2) were evaluated by our medical weight loss specialist prior to undergoing a planned incisional hernia repair. The mean weight of the patients preoperatively was 128 kg ± 25 (range 96-205 kg) (mean ± standard deviation), and the mean BMI was 49 kg/m(2) ± 10 (range 36-85). After completion of the preoperative modified protein sparing fast, the mean preoperative weight loss of the group was 24 kg ± 21 (range 2-80 kg). The overall change in BMI for the group prior to surgery was 9 kg/m(2) ± 8 (0.6 to 33). The percentage of excess BMI loss and total BMI loss preoperatively was 37 % ± 23 (2 to 83) and 18 % ± 12 (1 to 43), respectively. Of the 24 patients that initially lost weight in the program preoperatively, 22 (88 %) successfully maintained their weight loss for the entire study period for an average of 18 months. Collaboration with a medical weight loss specialist and a surgeon with a structured approach using a modified protein sparing fast can successfully result in meaningful weight loss prior to complex abdominal wall reconstruction. The majority of patients in this study were able to maintain their weight loss during long-term follow-up. Utilization of a protein sparing modified fast in collaboration with a medical weight loss specialist is a valuable resource for guiding weight loss in patients with morbid obesity prior to elective complex surgical procedures.
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Lamoshi AY, Hobbs GR, Khan FJ. Factors affecting hernia recurrence after Strattice mesh repair: A retrospective study. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Abdulraouf Y. Lamoshi
- Department of General Surgery; West Virginia University; Morgantown West Virginia USA
| | - Gerry R. Hobbs
- Department of General Surgery; West Virginia University; Morgantown West Virginia USA
| | - Fawad J. Khan
- Department of General Surgery; West Virginia University; Morgantown West Virginia USA
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Patel PV, Merchant AM. Ventral Hernia Repair in the Morbidly Obese Patient: A Review of Medical and Surgical Approaches in the Literature. Bariatr Surg Pract Patient Care 2014. [DOI: 10.1089/bari.2014.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Punam V. Patel
- Department of Surgery, Rutgers—New Jersey Medical School, Newark, New Jersey
| | - Aziz M. Merchant
- Department of Surgery, Rutgers—New Jersey Medical School, Newark, New Jersey
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Use of Morphometric Assessment of Body Composition to Quantify Risk of Surgical-Site Infection in Patients Undergoing Component Separation Ventral Hernia Repair. Plast Reconstr Surg 2014; 133:559e-566e. [DOI: 10.1097/prs.0000000000000009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
Repair of huge ventral hernias is technically challenging for the surgeon and a major operation for the patient and should be performed by experienced surgeons in centers that are used to caring for patients who are commonly massively obese with significant comorbidities. Preoperative medical optimization of patients is an important part in the overall management of these large hernias. Conventional component separation with retromuscular mesh repair is the workhorse operation, which successfully deals with many giant ventral hernias, but multiple alternative strategies must be available to address situations in which myofascial elements are completely deficient or there is significant loss of domain The complexity of this surgery is reflected by recurrence rates ranging from 10% to 30% and wound complication rates as high as 40% to 50% in experienced centers.
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Affiliation(s)
- Jai Bikhchandani
- Department of General Surgery, Creighton University Medical Center, 601 N 30th Street, Omaha, NE 68131, USA.
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21
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Lau B, Kim H, Haigh PI, Tejirian T. Obesity Increases the Odds of Acquiring and Incarcerating Noninguinal Abdominal Wall Hernias. Am Surg 2012. [DOI: 10.1177/000313481207801024] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The current data available describing the relationship of obesity and abdominal wall hernias is sparse. The objective of this study was to investigate the current prevalence of noninguinal abdominal wall hernias and their correlation with body mass index (BMI) and other demographic risk factors. Patients with umbilical, incisional, ventral, epigastric, or Spigelian hernias with or without incarceration were identified using the regional database for 14 hospitals over a 3-year period. Patients were stratified based on their BMI. Univariate and multivariate analyses were performed to distinguish other significant risk factors associated with the hernias. Of 2,807,414 patients, 26,268 (0.9%) had one of the specified diagnoses. Average age of the patients was 52 years and 61 per cent were male. The majority of patients had nonincarcerated umbilical hernias (74%). Average BMI was 32 kg/m2. Compared with patients with a normal BMI, the odds of having a hernia increased with BMI: BMI of 25 to 29.9 kg/m2 odds ratio (OR) 1.63, BMI of 30 to 39.9 kg/m2 OR 2.62, BMI 40 to 49.9 kg/m2 OR 3.91, BMI 50 to 59.9 kg/m2 OR 4.85, and BMI greater than 60 kg/m2 OR 5.17 ( P < 0.0001). Age older than 50 years was associated with a higher risk for having a hernia (OR, 2.12; 95% [CI], 2.07 to 2.17), whereas female gender was associated with a lower risk (OR, 0.53; 95% CI, 0.52 to 0.55). Those with incarcerated hernias had a higher average BMI (32 kg/m2 vs 35 kg/m2; P < 0.0001). Overall, BMI greater than 40 kg/m2 showed an increased chance of incarceration, and a BMI greater than 60 kg/m2 had the highest chance of incarceration, OR 12.7 ( P < 0.0001). Age older than 50 years and female gender were also associated with a higher risk of incarceration (OR, 1.28; 95% CI, 1.02 to 1.59 and OR, 1.80; CI, 1.45 to 2.24). Increasing BMI and increasing age are associated with a higher prevalence and an increased risk of incarceration of noninguinal abdominal wall hernias.
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Affiliation(s)
- Briana Lau
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Hanjoo Kim
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Philip I. Haigh
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Talar Tejirian
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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Chowbey PK, Sharma A, Mehrotra M, Khullar R, Soni V, Baijal M. Laparoscopic repair of ventral / incisional hernias. J Minim Access Surg 2011; 2:192-8. [PMID: 21187995 PMCID: PMC2999784 DOI: 10.4103/0972-9941.27737] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Despite its significant prevalence, there is little in the way of evidence-based guidelines regarding the timing and method of repair of incisional hernias. To add to the above is the formidable rate of recurrence that has been seen with conventional tissue repairs of these hernias. With introduction of different prosthetic materials and laparoscopic technique, it was hoped that an improvement in the recurrence and complication rates would be realized. The increasing application of the laparoscopic technique across the world indicates that these goals might indeed be achieved.
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Affiliation(s)
- Pradeep K Chowbey
- Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi - 110 060, India
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23
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Schumpelick V, Klinge U, Rosch R, Junge K. Light weight meshes in incisional hernia repair. J Minim Access Surg 2011; 2:117-23. [PMID: 21187980 PMCID: PMC2999769 DOI: 10.4103/0972-9941.27722] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Incisional hernias remain one of the most common surgical complications with a long-term incidence of 10–20%. Increasing evidence of impaired wound healing in these patients supports routine use of an open prefascial, retromuscular mesh repair. Basic pathophysiologic principles dictate that for a successful long-term outcome and prevention of recurrence, a wide overlap underneath healthy tissue is required. Particularly in the neighborhood of osseous structures, only retromuscular placement allows sufficient subduction of the mesh by healthy tissue of at least 5 cm in all directions. Preparation must take into account the special anatomic features of the abdominal wall, especially in the area of the Linea alba and Linea semilunaris. Polypropylene is the material widely used for open mesh repair. New developments have led to low-weight, large-pore polypropylene prostheses, which are adjusted to the physiological requirements of the abdominal wall and permit proper tissue integration. These meshes provide the possibility of forming a scar net instead of a stiff scar plate and therefore help to avoid former known mesh complications.
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24
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Babar M, Myers E, Matingal J, Hurley MJ. The modified Nyhus–Condon femoral hernia repair. Hernia 2010; 14:271-5. [DOI: 10.1007/s10029-009-0606-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 12/04/2009] [Indexed: 11/24/2022]
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Retraction and fibroplasia in a polypropylene prosthesis: experimental study in rats. Hernia 2009; 14:291-8. [PMID: 20035361 DOI: 10.1007/s10029-009-0607-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 12/04/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND The treatment of hernia, independent of anatomical site and technique utilized, generally involves using prostheses, which may cause complications, despite their unarguable advantage in allowing safe reinforcement. An example of this is possible retraction, which causes discomfort and hernia recurrence. Polypropylene is still the most often used biomaterial of the great number available. The purpose of this study is to evaluate the amount of retraction of the polypropylene mesh, as well as the histological reactions that accompany this phenomenon. METHODS Polypropylene meshes (Marlex) were inserted in an anterior position to the whole abdominal aponeurosis of 25 Wistar rats (Rattus norvegicus albinus). The animals were divided into groups and another intervention was performed 7, 28, and 90 days later to measure the dimensions of the prostheses and to calculate the final area. Histological analysis was performed with hematoxylin-eosin to evaluate neutrophils, macrophages, giant cells, and lymphocytes surrounding the mesh threads in ten random fields of each slide. RESULTS Seven days after the mesh was inserted, the mean rate of retraction was 1.75% (P = 0.64); at 28 days, it was 3.75% (P = 0.02); and at 90 days, it was 2.5% (P = 0.01). As to the histological analysis, there was a total decline of neutrophils and a progressive increase of macrophages, giant cells, and lymphocytes proportional to the post-implant time of the mesh (P < 0.05). CONCLUSION There was a statistically significant retraction of 3.75% at 28 days and 2.5% at 90 days after the prosthesis was inserted. There is a well-established sequence of cellular events which aim at synthesizing new connective tissue to reinforce the mesh.
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26
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Longterm Results of a Prospective Study of 225 Femoral Hernia Repairs: Indications for Tissue and Mesh Repair. J Am Coll Surg 2008; 207:360-7. [DOI: 10.1016/j.jamcollsurg.2008.04.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 04/08/2008] [Accepted: 04/08/2008] [Indexed: 11/15/2022]
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Incisional hernia after McBurney incision: retrospective case-control study of risk factors and surgical treatment. World J Surg 2008; 32:596-601; discussion 602-3. [PMID: 18175172 DOI: 10.1007/s00268-007-9342-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Few reports have dealt with incisional hernias originating at a McBurney incision after appendectomy. The purpose of the present study was to identify risk factors for development of incisional hernia at a McBurney incision, and to describe our experience with the treatment of this kind of hernia. PATIENTS AND METHODS We reviewed 4,862 files of patients older than 15 years of age operated on for acute appendicitis. Some 4,523 (93%) of that group were operated on through a McBurney incision, and 34 (0.7%) of them developed incisional hernia. To identify risk factors for development of incisional hernia we used binary logistic regression analysis. RESULTS The following risk factors were identified: female gender (p = 0.011), diabetes (p < 0.0001), peritonitis, abscess or phlegmon as the cause of the first operation (p = 0.009), wound infection (p = 0.034), seroma (p = 0.023), the use of catgut to suture the aponeurosis (p < 0.0001), and interrupted suture to the aponeurotic layer (p = 0.046). Twenty-two hernias were repaired with Mayo-herniorrhaphy and 12 with a subaponeurotic polypropylene prosthesis. Recurrences developed in 3 patients, none in hernias repaired with prosthesis. CONCLUSIONS The risk of incisional hernia after a McBurney incision for acute appendicitis was very low; we recommend the repair of this uncommon incisional hernia with current standard tension-free prosthetic techniques.
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Ching SS, Sarela AI, Dexter SPL, Hayden JD, McMahon MJ. Comparison of early outcomes for laparoscopic ventral hernia repair between nonobese and morbidly obese patient populations. Surg Endosc 2008; 22:2244-50. [PMID: 18622552 DOI: 10.1007/s00464-008-0039-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 05/08/2008] [Accepted: 05/20/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Obesity predisposes to incisional herniation and increased the incidence of recurrence after conventional open repair. Only sparse data on the safety and security of laparoscopic ventral hernia repair (LVHR) for morbidly obese patients are available. This study compared the incidence of perioperative complications and early recurrence after LVHR between morbidly obese and non-morbidly obese patients. METHODS The case records of consecutive patients who underwent LVHR between December 2002 and August 2007 were reviewed. Patients with a body mass index (BMI) lower than 35 kg/m2 were compared with morbidly obesity patients who had a BMI of 35 kg/m2 or higher. RESULTS The study included 168 patients (87 men) with a median age of 55 years (range, 24-92 years). Two conversions to open repair (1.2%) were performed, both for non-morbidly obese patients. Of the 168 patients, 42 (25%) were morbidly obese (BMI range, 35.0-58.0 kg/m2) and 126 (75%) were non-morbidly obese (BMI range, 15.5-34.9 kg/m2). The groups showed no significant differences in age, gender, number or size of fascial defects, operative time, length of hospital stay, or incidence of perioperative complications. At a median follow-up period of 19 months (range, 6-62 months), 20 patients (12%) had recurrent hernias. The incidence of recurrence was significantly associated with the size of the fascial defect and the size of the mesh, but not with morbid obesity. CONCLUSION No significant difference in the incidence of perioperative complications or recurrence after LVHR was observed between the morbidly obese patients and the non-morbidly obese patients.
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Affiliation(s)
- Siok S Ching
- Academic Unit of Surgery, The General Infirmary at Leeds, Great George Street, Leeds, West Yorkshire LS1 3EX, UK.
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d'Acampora AJ, Kestering DDM, Soldi MDS, Rossi LF. Experimental study comparing the tensile strength of different surgical meshes following aponeurotic-muscle deformity synthesis on Wistar rats. Acta Cir Bras 2007; 22:47-52. [PMID: 17293950 DOI: 10.1590/s0102-86502007000100009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 10/18/2006] [Indexed: 11/22/2022] Open
Abstract
PURPOSE: To assess the tensile strength of polypropylene and polypropylene associated with polyglactin meshes (Vypro II® - Ethicon®, Somerville, NJ, USA) in a situation of partial separation of abdominal muscle aponeurosis on rats. METHODS: Thirty rats were used of the Wistar strain, which were randomized into two groups of 15 specimens each. In both groups an aponeurotic-muscle deformity was created on the abdominal wall measuring 3.0 x 1.0 cm, which was closed with polypropylene mesh (polypropylene group) or Vypro® mesh (vypro group). After 28 days the rats underwent euthanasia and an area was removed from the abdominal wall with which a strip was made measuring 2.0 cm in length and 6.0 cm in width comprising the abdominal muscles with the implanted mesh. This sample was placed in a mechanical test machine in which a constant force was applied contrary to the tissue strips. Maximum force expressed in Newton was considered until full rupture of the sample occurred. The non-parametric Kruskal - Wallis test was used for statistical analysis admitting p<0.05. RESULTS: Out of the thirty animals, there were two deaths in the vypro group and one unit in the polypropylene group was lost. One animal in the polypropylene group developed hernia during the study and another one developed granuloma of the abdominal wall. All animals in both groups developed epiplon adherence to the mesh. The average force was 48.08 N for the polypropylene group and 45.32 for the vypro® group. CONCLUSION: In these experimental conditions it could be observed that there is no statistically significant difference in the rupture force of the polypropylene and Vypro® meshes (p=0.54).
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Vidović D, Jurisić D, Franjić BD, Glavan E, Ledinsky M, Bekavac-Beslin M. Factors affecting recurrence after incisional hernia repair. Hernia 2006; 10:322-5. [PMID: 16705360 DOI: 10.1007/s10029-006-0097-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Accepted: 04/13/2006] [Indexed: 11/25/2022]
Abstract
Incisional hernias occur primarily as a result of high tension and inadequate healing of a previous incision, the latter of which is frequently related to infection at the surgical site. Despite recent advances in operative techniques, the recurrence rate remains unacceptably high. To evaluate the impact of different predisposing factors for the recurrence of incisional hernia, we reviewed retrospectively the medical records of 297 patients who had undergone incisional herniorrhaphy (188 tissue repairs, 109 mesh repairs) in our hospital. Demographic data (age and gender), type of repair, body mass index, hernia size, presence of chronic illnesses and wound complications were evaluated in a univariate and multivariate manner analysis. The overall recurrence rate was 30.3%, with the recurrence rate in patients who underwent tissue repair being 39.4% and that in patients following prosthetic repair 14.6%. The recurrence rate was significantly influenced by type of repair, obesity, hernia size, wound healing disorders and some chronic comorbidities. We conclude that it is necessary to become familiar with the risk factors for recurrence of incisional hernia in order to eliminate or decrease their effect on the positive outcome of incisional herniorrhaphy.
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Affiliation(s)
- D Vidović
- Department of Surgery, University Hospital Sestre Milosrdnice, Vinogradska 29, 10 000 Zagreb, Croatia.
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31
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Abstract
Even with the routine use of mesh, repairing an incisional hernia is a challenge. Increasing evidence of impaired wound healing in these patients supports routine use of an open prefascial, retromuscular mesh repair. Basic pathophysiologic principles dictate that for a successful long-term outcome and prevention of recurrence a wide overlap underneath healthy tissue is required. The extent of this overlap should be 5 cm in all directions: surrounding the wound closure, subxiphoidal underneath the ribs, below the arcuate line, and retropubic.
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Affiliation(s)
- Uwe Klinge
- Surgical Department, Rhenisch Westfalian Technical University, Pauwelsstrass 30, Aachen, D 52074, Germany.
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