Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A systematic review and meta-analysis

Early wound morbidity and clinical outcomes associated with P4HB mesh compared to permanent synthetic mesh in umbilical and small to medium, routine ventral hernia repairs

Background

Permanent synthetic meshes such as polypropylene (PP) have been utilized for hernia repair for decades, but concerns remain regarding potential long-term, mesh-related complications. A resorbable polymer such as poly-4-hydroxybutyrate (P4HB) represents an alternative with high initial strength, that gradually resorbs, leaving an abdominal wall that is at least as strong as it would be in its native state. We aimed to compare early wound morbidity and clinical outcomes associated with P4HB to traditional, permanent PP in umbilical and small to medium, routine ventral hernias using data from the Abdominal Core Health Quality Collaborative (ACHQC).

Methods

Inclusion criteria for the umbilical cohort included: all Centers for Disease Control and Prevention (CDC) wound classes, all Ventral Hernia Working Group (VHWG) hernia grades, and hernia defects <3 cm. The small to medium, routine ventral hernia cohort was limited to CDC class I wounds, VHWG hernia grades I and II, and hernia defects <5 cm. The study group was comprised of P4HB meshes; the comparator group was an aggregate of PP meshes. Clinical outcomes were assessed at 30 days.

Results

There was no significant difference in early wound morbidity, readmission, or reoperation between the P4HB and PP cohorts. A small number of patients experienced SSO, with ≤4% requiring procedural intervention. None of the patients (0% in all cases) experienced skin/soft tissue necrosis, infected seroma, infected hematoma, exposed/contaminated/infected mesh, enterocutaneous fistula, graft failure, or pain requiring intervention at 30-days. However, P4HB was associated with significantly greater operative time, length of stay, and use of myofascial release compared to PP (p < 0.05 in all cases).

Conclusions

Short-term clinical outcomes associated with resorbable P4HB mesh are comparable to permanent synthetic PP mesh in umbilical and small to medium, routine ventral hernia repairs, despite significant differences in operative time and length of stay. Longer-term follow-up is needed to expand on the clinical relevance of these short-term findings.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation

PURPOSE

Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. An important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4 × 4 cm onlay-mesh for umbilical hernias ≤ 2 cm.

METHODS

A retrospective study was conducted at a single centre in Sweden on all umbilical hernia repairs during 2015-2019. The follow-up time was at least four months. Patients were identified using the hospital medical database. Repairs performed with suture or a sublay, ventral patch and laparoscopic mesh positioning were excluded. The patient's demographics, comorbidities, intra-and post-operative details were considered. The primary outcome was surgical site complications within 30 days. The secondary outcome was a recurrence.

RESULTS

80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm. The median (range) follow-up time was 29.0 (4.3-50.1) months. The median age was 46 (26-76) years old. The median body mass index was 28 (19-38) kg/m2. The male to female ratio was 2:1. 4 patients were identified with a surgical site post-operative complication; three with seromas and one with a superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound openings bedside. There were no registered cases of recurrence.

CONCLUSIONS

Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess whether mesh can reduce recurrences in umbilical hernia repairs ≤ 2 cm.

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

BACKGROUND

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

METHOD

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

RESULTS

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

DISCUSSION

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

Incarcerated Epigastric Hernia

An epigastric hernia is a form of ventral hernia. Most of these contain preperitoneal fat or the omentum. Herniation of intra-abdominal organs, a rare form of rectus sheath midline herniations, is seldom seen, and incarcerations in these cases are rare. A 56-year-old male presented with complaints of irreducible epigastric swelling. Thorough clinical examination and imaging studies revealed that the patient had an epigastric hernia. An intraoperative image showed that the small bowel had herniated through the epigastric defect and was obstructed; however, the small bowel was viable. The contents were reduced after enlarging the constricting ring, and anatomical repair with mesh reinforcement was done. Postoperatively, the patient had an uneventful recovery and was discharged.

Relationship between Preoperative Abdominal Wall Strength and Bulging at the Abdominal Free Flap Donor Site for Breast Reconstruction

BACKGROUND

Abdominal bulging at the donor site of free abdominal flaps for breast reconstruction is a common postoperative complication. In addition to the thickness of abdominal muscles, the authors identified the rectus abdominis diastasis as an important factor that compromises abdominal wall strength. This study aimed to assess the relationship between preoperative abdominal wall strength and postoperative abdominal bulging.

METHODS

A total of 224 patients were enrolled in this study. Patient demographics, the rectus and lateral abdominis muscle thicknesses, and the rate of rectus abdominis diastasis were compared (with versus without bulging). Muscle thickness and rectus abdominis diastasis were investigated by preoperative computed tomography.

RESULTS

The group with bulging consisted of 32 patients (14.3 percent), whereas the group without bulging consisted of 192 patients. The group with bulging had a significantly higher gestational history rate. The thickness of the rectus abdominis muscle in the group with bulging was significantly thinner (median, 8.6 mm versus 10.5 mm; p < 0.001) and the rate of rectus abdominis diastasis was significantly higher (78.1 percent versus 32.3 percent; p < 0.001). There were no significant differences with respect to the thickness of the lateral abdominal muscle and the other factors (i.e., age, body mass index, history of laparotomy. and operative details).

CONCLUSIONS

Because the diagnosis of abdominal bulging was based on severity, the rate may be high compared to that reported from previous studies. Because the factor of gestational history correlated to thickness of the rectus abdominis muscle and rectus abdominis diastasis, this factor influenced the occurrence of abdominal bulging. Patients with a thin rectus abdominis muscle and rectus abdominis diastasis were at higher risk of abdominal bulging.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Umbilical hernia repair and recurrence: need for a clinical trial?

INTRODUCTION

Umbilical hernia repair, despite its perceived simplicity, is associated with recurrence between 2.7 and 27%, in mesh repair and non mesh repair respectively. Many factors are recognized contributors to recurrence however multiple defects in the linea alba, known to occur in up to 30% of patients, appear to have been overlooked by surgeons.

AIMS

This systematic review assessed reporting of second or multiple linea alba defects in patients undergoing umbilical hernia repair to establish if these anatomical variations could contribute to recurrence along with other potential factors.

METHODS

A systematic review of all published English language articles was undertaken using databases PubMed, Embase, Web of Science and Cochrane Library from January 2014 to 2019. The search terms 'Umbilical hernia' AND 'repair' AND 'recurrence' were used across all databases. Analysis was specified in advance to avoid selection bias, was registered with PROSPERO (154173) and adhered to PRISMA statement.

RESULTS

Six hundred and forty-six initial papers were refined to 10 following article review and grading. The presence of multiple linea alba defects as a contributor to recurrence was not reported in the literature. One paper mentioned the exclusion of six participants from their study due multiple defects. In all 11 factors were significantly associated with umbilical hernia recurrence. These included: large defect, primary closure without mesh, high BMI in 5/10 publications; smoking, diabetes mellitus, surgical site Infection (SSI) and concurrent hernia in 3/10. In addition, the type of mesh, advanced age, liver disease and non-closure of the defect were identified in individual papers.

CONCLUSION

This study identified many factors already known to contribute to umbilical hernia recurrence in adults, but the existence of multiple defects in the linea, despite it prevalence, has evaded investigators. Surgeons need to be consider documentation of this potential confounder which may contribute to recurrence.

Innovations in surgical treatment of rectus abdominis diastasis: a review of mini-invasive techniques

Abdominal rectus diastasis (RD) is characterized by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This condition is associated with bulging of abdominal content, and it is mostly acquired during pregnancy or obesity. Symptoms include pain and discomfort in the abdomen, musculoskeletal and uro-gynecological problems in addition to negative body image and impaired quality of life. In this review we present current knowledge on the novel surgical mini-invasive techniques for treatment of RD. The aim of our study is to discuss the use of a standard classification to define pathological RD and possible indications for a minimally invasive repair, considering complications, patients' satisfaction and recurrence rate. A PubMed search of the literature has been conducted in January 2020 including the most recent articles using the following criteria among the interventions for RD: mini-invasive surgery, laparoscopic, endoscopy and robotic procedures. Minimally invasive surgical treatment options for rectus diastasis are poorly investigated and indications for repair are still debated. Guidelines are mandatory to standardize surgical management of RD.

SUMMER Trial: mesh versus suture repair in small umbilical hernias in adults-a study protocol for a prospective randomized double-blind multicenter clinical trial

Background

Small umbilical hernia repair is one of the most common surgical performances in general surgery. Yet, a gold standard procedure for the repair is still lacking today. There is an increasing evidence that mesh could be advantageous compared to suture repair in lowering recurrence rates. An additional important question remains with regard to the optimal anatomical positioning of the mesh. We hypothesize that the use of an onlay mesh in small umbilical hernia defects can reduce recurrence rates without increasing the complications compared to a simple suture repair.

Methods

A prospective, national, multicenter, randomized, double-blind clinical trial comparing a standardized 4 × 4 cm onlay mesh to a conventional suture repair will be conducted. A total of 288 patients with a primary elective umbilical hernia ≤ 2 cm from 7 participating Swedish surgical centers will be enrolled. Intraoperative randomization will take place using a centralized web-based system resulting in total allocation concealment. Stratification will be done by surgical site and by defect size. Trial participants and follow-up clinical surgeons will be blinded to the assigned allocation. The primary outcome assessed will be postoperative recurrence at 1 and 3 years. Secondary outcomes assessed will be postoperative complications at 30 days and pain 1 year after surgery.

Discussion

Currently, there has been no randomized clinical trial comparing the recurrence rates between an onlay mesh repair and a simple suture repair for small umbilical hernia defects. How to best repair a small umbilical hernia continues to be debated. This trial design should allow for a good assessment of the differences in recurrence rate due to the large sample size and the adequate follow-up. Surgeons’ concerns surrounding optimal anatomical positioning and fear for larger required dissections are understandable. A small onlay mesh may become an easy and safe method of choice to reduce recurrence rates. Guidelines for small umbilical hernia repairs have stressed the need for reliable data to improve treatment recommendations. We can expect that this trial will have a direct implication on small umbilical hernia repair standards.

Trial registration

ClinicalTrials.gov NCT04231071. Registered on 31 January 2020. SUMMER Trial underwent external peer review as part of the funding process.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current practice patterns for initial umbilical hernia repair in the United States

PURPOSE

The approach to repairing an initial umbilical hernia (IUH) varies substantially, and this likely depends on hernia size, patient age, sex, BMI, comorbidities including diabetes mellitus, and surgeon preference. Of these, only hernia size has been widely studied. This cross-sectional study aims to look at the practice pattern of umbilical hernia repair in the United States.

METHODS

A retrospective study was performed using data from the America Hernia Society Quality Collaborative. Patient characteristics included age, sex, hernia width, BMI, smoking status, and diabetes. Outcomes were use of mesh for repair, as well as surgical approach (open vs minimally invasive). Multivariate logistic regression was performed to assess the independent effect of age, sex, hernia width, BMI, smoking status, and diabetes on use of mesh and approach to repair.

RESULTS

3475 patients were included. 74% were men. Mesh use was more common in men (67% vs 60%, P < 0.001). Mesh was used in 33% of repairs ≤ 1 cm, and 82% of repairs > 1 cm (P < 0.001). Younger patients were less likely to receive a mesh repair (54% if age ≤ 35 vs 67% for age > 35, P < 0.001). However, on multivariate analysis, mesh use was associated with increasing hernia width (OR 5.474, 95% CI 4.7-6.3) as well as BMI (OR 1.8, 95% CI 1.5-2.1) but not with age or sex.

CONCLUSION

The majority of IUH are performed open. Patient BMI and hernia defect size contribute to choice of surgical technique including use of mesh. The use of mesh in 33% of hernias below 1 cm demonstrates a gap between evidence and practice. Patient factors including patient age and sex had no impact on operative approach or use of mesh.

Mesh OR Patch for Hernia on Epigastric and Umbilical Sites (MORPHEUS-Trial): The Complete Two-year Follow-up

OBJECTIVE

The objective of this trial was to identify a superior method for umbilical and epigastric hernia repair in terms of complications. Complications such as an extended operation duration, additional use of painkillers, reoperation, infection, seroma, extended wound care, extended hospitalization, and early recurrence were reported according to the Clavien-Dindo grading system.

SUMMARY BACKGROUND DATA

Over the years mesh repair is proven the gold standard for umbilical and epigastric hernias. The question remains, which mesh should be used?

METHODS

In this randomized controlled, multicenter trial, all patients ≥ 18 years with a single, symptomatic, and primary small umbilical or epigastric hernia qualified for inclusion. Flat preperitoneal polypropylene mesh repair was compared with patch repair (PROCEED Ventral Patch) (PVP).

RESULTS

A total of 352 patients were randomized; 348 patients received the intervention (n = 177 PVP vs n = 171 mesh). One out of 4 suffered from any kind of complication within 2 years postoperative (27.6%). A significant difference in complications was seen, in favor of polypropylene mesh repair (P = 0.044, 22.1% mesh vs 32.5% PVP). Reoperation was performed in 19 PVP operated patients (10.7%) versus 7 patients with polypropylene mesh repair (4.0%, P = 0.021).No significant differences were seen in recurrences (n = 13, 8.4% PVP vs n = 6, 4.1% mesh, P = 0.127).

CONCLUSIONS

In small epigastric and small umbilical hernia repair a flat polypropylene mesh repair was associated with a lower complication rate than PVP repair. No differences in recurrence rates were seen. Combining all complications, the preperitoneal positioned flat polypropylene mesh performed better.

Local anaesthetic repair of paraumbilical hernia as a safe option across a range of body mass indices

INTRODUCTION

Local anaesthetic repair of paraumbilical hernia (PUH) is a commonly performed operation. The aim of this study was to investigate whether local anaesthesia (LA) repair of PUH was feasible in patients with a high body mass index (BMI) and whether BMI had an impact on patient reported pain scores.

METHODS

Patients undergoing PUH repair under the care of single consultant in a district general hospital between March 2010 and January 2018 were recruited. Patient demographics, BMI, duration of operation, volume of LA infiltrated and grade of operating surgeon were available from the consultant's database. The database also included prospectively recorded patient reported pain scores based on a numerical scale (0-100) and overall patient satisfaction measured as a percentage. Patients were divided into three BMI categories: <25kg/m², 25-30kg/m² and >30 kg/m².

RESULTS

A total of 123 patients underwent PUH repair under LA during the study period. Six patients had no recorded BMI and were excluded from the analysis. Of the remaining 117 patients, 36 (31%) were in the normal BMI range, 35 (30%) in the overweight range and 46 (39%) in the obese range. There was no statistically significant difference between the BMI groups in terms of volume of LA used, duration of operation, postoperative pain scores or patient satisfaction.

CONCLUSIONS

LA repair of PUH is feasible for patients with a raised BMI and does not result in higher postoperative pain scores or the need for higher doses of LA.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach?

PURPOSE

Ventral hernia repair has become a common procedure, but the way in which it is performed still depends on surgeon's skill, experience, and habit. The initial open approach is faced with extensive dissection and a high risk of infection and prolonged hospital stay. To tackle these problems, minimally invasive procedures are gaining interest. Several new techniques are emerging, but laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. We will discuss why laparoscopic IPOM is still a valuable approach in the treatment of primary non-complicated midline hernias and review the current literature.

METHODS

We performed a literature search across PubMed and MEDLINE using the following search terms: "Laparoscopic hernia repair", "Ventral hernia repair" and "Primary ventral hernia". Articles corresponding to these search terms were individually reviewed by the primary author and selected on relevance.

CONCLUSION

Laparoscopic IPOM still is a good approach for the efficient treatment of primary non-complicated midline hernias. Several techniques are emerging, but are faced with increased costs, technical difficulties, and low study patient volume. Further research is warranted to show superiority and applicability of these new techniques over laparoscopic IPOM, but until then laparoscopic IPOM should remain the go-to technique.

Open ventral hernia repair with a composite ventral patch - final results of a multicenter prospective study

Background

This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex™ Composite Ventral Patch (PCO-VP).

Methods

A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed.

Results

One hundred twenty-six subjects (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8 cm (0.4–4.0) were treated with PCO-VP. One hundred subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0–6.3%) within 24 months. Median Numeric Rating Scale pain scores improved from 2 [0–10] at baseline to 0 [0–3] at 1 month (P < 0.001) and remained low at 24 months 0 [0–6] (P < 0.001). 99% (102/103) of the patients were satisfied with their repair at 24 months postoperative.

Conclusions

The use of PCO-VP to repair primary umbilical and epigastric defects yielded a low recurrence rate, low postoperative and chronic pain, and high satisfaction ratings, confirming that PCO-VP is effective for small ventral hernia repair in the two-year term after implantation.

Trial registration

The study was registered publically at clinicaltrials.gov (NCT01848184 registered May 7, 2013).

Voluminous paraumbilical hernia containing the pancreas - An unusual cause of acute pancreatitis: A case report

Introduction

The paraumbilical hernia sac often contains the omentum, the small bowel, and less commonly the colon. The herniation of the pancreas through a paraumbilical hernia is extremely rare and has been reported only by two cases in the literature; moreover, acute pancreatitis secondary to this condition is a particularly unusual event.

Case report

We present a very unusual case of a 67-year-old female patient with a voluminous paraumbilical hernia containing the pancreas, complicated by acute pancreatitis. Laboratory data revealed an elevation of the pancreatic enzymes. An intravenous contrast-enhanced computed tomography (CT) scan of the abdomen demonstrated a large hernia sac containing multiple viscera, including the pancreas. The patient underwent emergency laparotomy with a diagnosis of intestinal obstruction.

Conclusion

The clinicians should consider this rare condition in the differential diagnosis of patients presenting with large paraumbilical hernias associated with classical symptoms of acute pancreatitis, particularly in the absence of typical risk factors for pancreatitis. An intravenous contrast-enhanced abdominal CT scan should be performed immediately in these patients. We recommend the patients and the surgeons to consider prompt surgical repair for paraumbilical hernias to avoid further complications and the higher incidence of morbidity and mortality associated with emergency surgeries.

Open mesh versus suture repair of umbilical hernia: Meta-analysis of randomized controlled trials

BACKGROUND

The optimal methodology of surgical treatment of umbilical hernia in adults remains controversial. Previously published randomized controlled trials (RCTs) and cohort studies have demonstrated advantage for open mesh over suture repair. Two published meta-analyses, including RCTs and retrospective cohort studies, have compared the outcomes of open mesh versus suture repair of umbilical hernia in adult, which were flawed since they included both elective and emergency repairs of umbilical hernias. The aim of this meta-analysis is to include RCTs to examine whether open mesh repair of umbilical hernia produces a better outcome than suture repair in adult patients.

METHODS

A literature search using Medline, Embase and Cochrane Database was performed, and meta-analysis was performed using RevMan 5.3.5 software. Outcomes evaluated incidence of hernia recurrence, wound infection, haematoma, seroma and patient death.

RESULTS

Of the 620 records identified, 4 RCTs, including 620 patients, were included in the meta-analysis. In the RCTS, when open mesh repair was compared with suture repair, open mesh repair was associated with significantly low incidence of recurrence (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.10-0.48; P = 0.0001). The incidence of wound infection (OR 0.89, 95% CI 0.35-2.31; P = 0.82), haematoma (OR 0.83, 95% CI 0.28-2.41; P = 0.73), and seroma (OR 2.01, 95% CI 0.82-4.91; P = 0.13), were similar between the two groups.

CONCLUSIONS

Open mesh repair was associated with significant reduction in the recurrence rate in comparison to suture repair of umbilical hernia.

Lower Risk of Recurrence After Mesh Repair Versus Non-Mesh Sutured Repair in Open Umbilical Hernia Repair: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIMS

The use of mesh repair in a small- or middle-sized umbilical hernia remains controversial, and evidence is based on only few and small heterogeneous randomized trials. The primary aim was to assess differences, if any, in recurrence (clinical and reoperation), and secondary aim was to assess differences in infections, seroma formation, hematomas, chronic pain, cosmetic result, and quality of life.

METHOD

A systematic review (predefined search strategy) and meta-analyses were conducted based on pre-study strict and well-defined methodology. The literature search was completed on 1 January 2018. The study protocol was registered in PROSPERO.

RESULTS

Five randomized controlled trials were identified (mesh repair, n = 326 versus non-mesh sutured repair, n = 330) and 602 records were excluded. Randomized controlled trials included patients with defect diameters of ⩾1 to 4 cm. Mesh repair reduced the risk of recurrence compared with sutured repair with a relative risk of 0.28 (95% confidence interval = 0.13-0.58, I² = 0%, number needed to treat = 13 patients). Additional analyses found no differences between the two surgical techniques regarding infection (relative risk = 0.80, 95% confidence interval = 0.36-1.79), seroma formation (relative risk = 1.38, 95% confidence interval = 0.57-3.32), or hematomas (relative risk = 0.55, 95% confidence interval = 0.23-1.30). Lack of sufficient data precluded meta-analysis evaluating risk of seroma formation, hematomas, chronic pain, cosmetic result, and quality of life.

CONCLUSION

Mesh repair is recommended for umbilical hernia of ⩾1 to 4 cm. More evidence is needed for the optimal placement of the mesh (sublay or onlay) and the role of mesh in patients with an umbilical hernia <1 cm.

Concomitant Abdominoplasty and Laparoscopic Umbilical Hernia Repair

BACKGROUND

Umbilical hernia is a common finding in patients undergoing abdominoplasty, especially those who are postpartum with rectus divarication. Concurrent surgical treatment of the umbilical hernia at abdominoplasty presents a "vascular challenge" due to the disruption of dermal blood supply to the umbilicus, leaving the stalk as the sole axis of perfusion. To date, there have been no surgical techniques described to adequately address large umbilical herniae during abdominoplasty.

OBJECTIVES

To present an effective and safe technique that can address large umbilical herniae during abdominoplasty.

METHODS

A prospective series of 10 consecutive patients, undergoing concurrent abdominoplasty and laparoscopic umbilical hernia repair between 2014 and 2017 were included in the study. All procedures were performed by the same general surgeon and plastic surgeon at the Macquarie University Hospital in North Ryde, NSW, Australia. Data were collected with approval of our ethics committee.

RESULTS

At 12-month follow up there were no instances of umbilical necrosis, wound complications, seroma, or recurrent hernia. The mean body mass index was 23.8 kg/m2 (range, 16.1-30.1 kg/m2). Rectus divarication ranged from 35 to 80 mm (mean, 53.5 mm). Umbilical hernia repair took a mean of 25.9 minutes to complete (range, 18-35 minutes).

CONCLUSIONS

We present a technique that avoids incision of the rectus fascia minimizes dissection of the umbilical stalk and is able to provide a gold standard hernia repair with mesh. This procedure is particularly suited to postpartum patients with large herniae (>3-4 cm diameter) and wide rectus divarication, where mesh repair with adequate overlap is the recommended treatment.

LEVEL OF EVIDENCE 4

Mesh Versus Patch Repair for Epigastric and Umbilical Hernia (MORPHEUS Trial); One-Year Results of a Randomized Controlled Trial

DESIGN

This trial is a randomized controlled, patient-blinded, multicentre, superiority trial.

METHODS

All patients ≥18 years with a single, symptomatic and primary umbilical or epigastric hernia (<2 fingers) qualified for participation in the study. Flat polypropylene mesh repair was compared to patch repair (PROCEED^® Ventral Patch) (PVP). The objective of this trial was to identify a superior method for umbilical and epigastric hernia repair in terms of complication rates.

RESULTS

A total of 352 patients were randomized in this trial; 348 patients received the intervention (n = 177 PVP vs. n = 171 mesh). No peri-operative complications occurred. PVP placement was significantly faster compared to mesh placement (30 min, SD 11 vs. 35 min, SD 11) and was scored as an easier procedure. At 1-month follow-up, 76 patients suffered any kind of complication. There was no significant difference in the proportion of complications (24.9% for PVP and 18.7% for mesh, p = 0.195). A significant difference was seen in re-operation rate within 1 month, significantly less early re-operations in the mesh group (0.0 vs. 2.8%, p = 0.027). After 1-year follow-up, no significant differences are seen in recurrence rates (n = 13, 7.8% PVP vs. n = 5, 3.3% mesh, p = 0.08).

CONCLUSIONS

Both mesh and PVP had a comparable amount of reported complications. There was a significantly higher incidence of early re-operations due to early complications in the PVP group. No differences were seen in infection rates and the need for antibiotic treatment. No significant difference was seen in the recurrence rates.

REGISTRATION

This trial was registered in the Dutch Trail Registry (NTR) NTR2514NL33995.060.10. [12].

Retrospective analysis of smaller than 3-cm umbilical hernia repair with the lightweight macroporous mesh

There is evidence that mesh repair for primary umbilical hernias results in fewer recurrences and similar wound complication rates compared to tissue repair. Various devices and surgical approaches are used in umbilical hernia repair. The ULTRAPRO PLUG (UPP) has been adopted for inguinal hernias and femoral hernias with excellent results. However, there are few reports on the use of UPP for umbilical hernia repair. Thus, the aim of this study was to evaluate efficacy and safety in the treatment of smaller than 3-cm umbilical hernias using the UPP.The medical records of 123 patients who underwent umbilical hernia repair using the UPP between October 2011 and September 2017 were reviewed. All patients were followed-up after 1 month and later in 2018. Demographics, surgical information, and immediate postoperative and long-term complications were assessed.Out of 123 patients, there were 37 male and 86 female patients with a mean age of 50.6 years. The median duration of hernia surgery was 20.5 min (range, 12-34), and 109 (88.6%) patients underwent day surgery. The median defect diameter was 1.4 cm (range, 0.5-3). No mortality or major complications occurred during the perioperative period. Long-term follow-up data were available for 107 (87.0%) patients. The median follow-up duration was 33 months (range, 5-76 months). Early postoperative complications included 1 case of seroma, 2 cases of fat liquefaction, and 1 case of superficial surgical site infection. During follow-up, there were 2 recurrences, 1 case of chronic mesh infection, and 2 patients with chronic postoperative pain.The ULTRAPRO PLUG offers a simple and quick means of repairing smaller than 3-cm umbilical hernias with lower recurrence rates and fewer postoperative complications.

Mesh repair of paraumblical hernia, outcome of 58 cases

Background

According to the literature, defects in para-umbilical hernias up to 2 cm in diameter could be sutured primarily. For defects larger than 2 cm in dimeters, mesh repair is recommended. The aim of this study is to evaluate the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

Methods

In this retrospective study, patients with para-umbilical hernia, who were managed by onlay mesh placement were presented, and followed for 1–6 years. Several variables were studied including patients' socio-demographic data, post-operative complications, morbidity and mortality.

Results

The series includes 58 patients, the age ranged from 18 to 85 years with median age of 44 years and inter-quartile range of 13.5 years. Mean body mass index was (30.9 ± 4.2). From 49 female patients; 43 (87.8%) were multipara. Forty seven cases (81%) presented for the first time, and 11 cases (19%) had recurrent hernias. Twenty patients (34.5%) had hernia defect ≤2 cm, while 38 patients (65.5%) had hernia size >2 cm. Superficial surgical site infection was found in 6 patients (10.34%). Seroma was found in one female patient (1.72%). One patient (1.72%) had recurrent hernia after 19 months.

Conclusion

Mesh onlay repair by open surgery can be applied to all sizes of para umbilical hernias, it has low recurrence rate and the rates of morbidity and recurrence are comparable with international standard.

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Defect in para-umbilical hernias up to 2 cm in diameter may be sutured primarily. For defects larger than 2 cm, mesh repair is recommended.

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A retrospective study of 58 paraumblical hernias that were treated with onlay mesh.

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The aim of this study is to confirm the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

A short term analysis of surgical management of umbilical and paraumbilical hernia

Objective

Umbilical hernia and paraumbilical hernia are ventral herniae that occur in infants and adults. According to current evidence, mesh repair is the treatment of choice to avoid recurrence. The aim of this study is to analyze the surgical methods, the types of meshes used, and their benefits.

Material and Methods

A retrospective analysis of patients diagnosed with umbilical hernia and paraumbilical hernia was performed. The patients' consent was obtained retrospectively. The various surgical techniques and different meshes used were analyzed. Forty-three patients were selected for the study. Of these, 23 patients underwent open mesh repair, 12 patients underwent laparoscopic intraperitoneal onlay mesh repair repair, and eight patients underwent open intraperitoneal onlay mesh repair repair. The duration of the surgery, mesh used, number of days of hospital stay, type of anesthesia, and postoperative complications were analyzed.

Results

Of the 43 patients, the patients who underwent open intraperitoneal onlay mesh repair had shorter postoperative hospital stays compared to other methods (median=1 day; range=1 to 2 days). The duration of surgery was longer for laparoscopic intraperitoneal onlay mesh repair and open mesh repair compared to the open intraperitoneal onlay mesh repair technique (p<0.05).

Conclusion

The open intraperitoneal onlay mesh repair technique had advantages over the other methods for small-defect umbilical hernia and paraumbilical hernia. The duration of surgery was long for laparoscopic intraperitoneal onlay mesh repair compared to open mesh repair and the open intraperitoneal onlay mesh repair technique. Postoperative complications were insignificant for all three methods. Another advantage of the open intraperitoneal onlay mesh repair technique was a shorter postoperative hospital stay.

Prospective Analysis of Epigastric, Umbilical, and Small Incisional Hernia Repair Using the Modified Kugel Oval Patch

The study was performed to determine the complication and recurrence rate using the modified Kugel oval patch for small ventral hernia repair. Another aim of the study was to find risk factors for recurrence in patients with this repair. Seventy-three patients underwent ventral hernia repair with the modified Kugel oval patch between April 2013 and February 2015. Prospective follow-up data (18 months postoperative) were collected and evaluated. A total of 58 primary (18 epigastric/40 umbilical) and 15 incisional ventral hernias were repaired with the modified Kugel oval patch (7.6/10.2 cm/8 x 12 cm). We found three patients suffered superficial wound infection and two participants got hernia recurrence. Placement of mesh was found to be a significant risk factor for hernia recurrence. Small ventral hernia repair using the modified Kugel oval patch is a novel and useful approach and we recommend placing the patch preperitoneally.

Long-term follow-up results of umbilical hernia repair

Introduction

Multiple suture techniques and various mesh repairs are used in open or laparoscopic umbilical hernia (UH) surgery.

Aim

To compare long-term follow-up results of UH repair in different hernia surgery groups and to identify risk factors for UH recurrence.

Material and methods

A retrospective analysis of 216 patients who underwent elective surgery for UH during a 10-year period was performed. The patients were divided into three groups according to surgery technique (suture, mesh and laparoscopic repair). Early and long-term follow-up results including hospital stay, postoperative general and wound complications, recurrence rate and postoperative patient complaints were reviewed. Risk factors for recurrence were also analyzed.

Results

One hundred and forty-six patients were operated on using suture repair, 52 using open mesh and 18 using laparoscopic repair technique. 77.8% of patients underwent long-term follow-up. The postoperative wound complication rate and long-term postoperative complaints were significantly higher in the open mesh repair group. The overall hernia recurrence rate was 13.1%. Only 2 (1.7%) patients with small hernias (< 2 cm) had a recurrence in the suture repair group. Logistic regression analysis showed that body mass index (BMI) > 30 kg/m², diabetes and wound infection were independent risk factors for umbilical hernia recurrence.

Conclusions

The overall umbilical hernia recurrence rate was 13.1%. Body mass index > 30 kg/m², diabetes and wound infection were independent risk factors for UH recurrence. According to our study results, laparoscopic medium and large umbilical hernia repair has slight advantages over open mesh repair concerning early postoperative complications, long-term postoperative pain and recurrence.

Factors Associated With Long-term Outcomes of Umbilical Hernia Repair

Importance

Umbilical hernia repair is one of the most commonly performed general surgical procedures. However, there is little consensus about the factors that lead to umbilical hernia recurrence.

Objective

To better understand the factors associated with long-term umbilical hernia recurrence.

Design, Setting, and Participants

A retrospective cohort of 332 military veteran patients who underwent umbilical hernia repair was studied between January 1, 1998, and December 31, 2008, at the VA Boston Healthcare System. Recurrence and mortality outcomes were tracked from that period until June 1, 2014. Data were collected on patient characteristics, operative, and postoperative factors and univariate and multivariable analyses were used to assess which factors were significantly associated with umbilical hernia recurrence and mortality. All patients with primary umbilical hernia repair, with or without a concurrent unrelated procedure, were included in the study. Patients excluded were those who underwent umbilical hernia repair as a part of another major planned procedure with abdominal incisions. Data were collected from June 1, 2014, to November 1, 2015. Statistical analysis was performed from November 2, 2015, to April 1, 2016.

Main Outcomes and Measures

The primary study outcomes were umbilical hernia recurrence and death.

Results

Of the 332 patients in this study, 321 (96.7%) were male, mean age was 58.4 years, and mean (SD) time of follow-up was 8.5 (4.1) years. The hernia recurrence rate was 6.0% (n = 20) at a mean 3.1 years after index repair (median, 1.0-year; range, 0.33-13 years). The primary suture repair recurrence rate was 9.8% (16 of 163 patients), and the mesh repair recurrence rate was 2.4% (4 of 169 patients). On univariate analysis, ascites (P = .02), liver disease (P = .02), diabetes (P = .04), and primary suture (nonmesh) repairs (P = .04) were significantly associated with increased recurrence rates. Patients who had a history of hernias (125 [39%]) were less likely to have umbilical hernia recurrences (χ21 = 4.65, P = .03). On multivariable regression analysis, obesity and ascites were associated with significantly increased odds ratios of recurrence of 3.3 (95% CI, 1.0-10.1) and 8.0 (95% CI, 1.8-34.4), respectively. Mesh repair was seen to decrease recurrence with odds of 0.28 (95% CI, 0.08-0.95). There was no significant difference in complication rates between mesh repair and primary suture repair. The survival rate was 73% (n = 242) at the end of the study. Factors associated with mortality were older age, smoking, liver disease, ascites, emergency or semiurgent repair, and need for intraoperative bowel resection.

Conclusions and Relevance

Ascites, liver disease, diabetes, obesity, and primary suture repair without mesh are associated with increased umbilical hernia recurrence rates. Elective umbilical hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.

A multicenter prospective study of patients undergoing open ventral hernia repair with intraperitoneal positioning using the monofilament polyester composite ventral patch: interim results of the PANACEA study

Purpose

This study assessed the recurrence rate and other safety and efficacy parameters following ventral hernia repair with a polyester composite prosthesis (Parietex™ Composite Ventral Patch [PCO-VP]).

Patients and methods

A single-arm, multicenter prospective study of 126 patients undergoing open ventral hernia repair with the PCO-VP was performed. Patient outcomes were assessed at discharge and at 10 days, 1, 6, 12, and 24 months postoperative.

Results

All patients had hernioplasty for umbilical (n = 110, 87.3%) or epigastric hernia (n = 16, 12.7%). Mean hernia diameter was 1.8 ± 0.8 cm. Mean operative time was 36.2 ±15.6 minutes, with a mean mesh positioning time of 8.1 ± 3.4 minutes. Surgeons reported satisfaction with mesh ease of use in 95% of surgeries. The cumulative hernia recurrence rate at 1 year was 2.8% (3/106). Numeric Rating Scale (NRS) pain scores showed improvement from 2.1 ± 2.0 at preoperative baseline to 0.5 ± 0.7 at 1 month postoperative (P < 0.001), and this low pain level was maintained at 12 months postsurgery (P < 0.001). The mean global Carolina’s Comfort Scale^® (CCS) score improved postoperatively from 3.8 ± 6.2 at 1 month to 1.6 ± 3.5 at 6 months (P < 0.001). One patient was unsatisfied with the procedure.

Conclusion

This 1-year interim analysis using PCO-VP for primary umbilical and epigastric defects shows promising results in terms of mesh ease of use, postoperative pain, and patient satisfaction. Recurrence rate is low, but, as laparoscopic evaluation shows a need for patch repositioning in some cases, an accurate surgical technique remains of utmost importance.

Risk-adjusted adverse outcomes in complex abdominal wall hernia repair with biologic mesh: A case series of 140 patients

INTRODUCTION

Biologic mesh is preferred for repair of complex abdominal wall hernias (CAWHs) in patients at high risk of wound infection. We aimed to identify predictors of adverse outcomes after complex abdominal wall hernia repair (CAWR) using biologic mesh with different placement techniques and under different surgical settings.

METHODS

A retrospective case series study was conducted on all patients who underwent CAWR with biologic mesh between 2010 and 2015 at a tertiary medical center.

RESULTS

the study population included 140 patients with a mean age of 54 ± 14 years and a median follow up period 8.8 months. Mesh size ranged from 50 to 1225 cm². Ninety percent of patients had undergone previous surgery. Type of surgery was classified as elective in 50.7%, urgent in 24.3% and emergent in 25.0% and a porcine mesh was implanted in 82.9%. The most common mesh placement technique was underlay (70.7%), followed by onlay (16.4%) and bridge (12.9%). Complications included wound complications (30.7%), reoperation (25.9%), hernia recurrence (20.7%), and mesh removal (10.0%). Thirty-two patients (23.0%) were admitted to the ICU and the mean hospital length of stay was 10.8 ± 17.5 days. Age-sex adjusted predictors of recurrence were COPD (OR 4.2; 95%CI 1.003-17.867) and urgent surgery (OR 10.5; 95%CI 1.856-59.469), whereas for reoperation, mesh size (OR 6.8; 95%CI 1.344-34.495) and urgent surgery (OR 5.2; 95%CI 1.353-19.723) were the predictors.

CONCLUSIONS

Using biologic mesh, one-quarter and one-fifth of CAWR patients are complicated with reoperation or recurrence, respectively. The operation settings and comorbidity may play a role in these outcomes regardless of the mesh placement techniques.

The feasibility of local anesthesia for the surgical treatment of umbilical hernia: a systematic review of the literature

Background

Yearly approximately 4500 umbilical hernias are repaired in The Netherlands, mostly under general anesthesia. The use of local anesthesia has shown several advantages in groin hernia surgery. Local anesthesia might be useful in the treatment of umbilical hernia as well. However, convincing evidence is lacking. We have conducted a systematic review on safety, feasibility, and advantages of local anesthesia for umbilical hernia repair.

Methods

A systematic review was conducted according to the PRISMA guidelines. Outcome parameters were duration of surgery, surgical site infection, perioperative and postoperative complications, postoperative pain, hernia recurrence, time before discharge, and patient satisfaction.

Results

The systematic review resulted in nine included articles. Various anesthetic agents were used, varying from short acting to longer acting agents. There was no consensus regarding the injection technique and no conversions to general anesthesia were described. The most common postoperative complication was surgical site infection, with an overall percentage of 3.4%. There were no postoperative deaths and no allergic reactions described for local anesthesia. The hernia recurrence rate varied from 2 to 7.4%. Almost 90% of umbilical hernia patients treated with local anesthesia were discharged within 24 h, compared with 47% of patients treated with general anesthesia. The overall patient satisfaction rate varied from 89 to 97%.

Conclusion

Local anesthesia for umbilical hernia seems safe and feasible. However, the advantages of local anesthesia are not sufficiently demonstrated, due to the heterogeneity of included studies. We, therefore, propose a randomized controlled trial comparing general versus local anesthesia for umbilical hernia repair.

Identifying Effectors of Outcomes in Patients with Large Umbilical Hernias

Quality of life (QOL) has become an important focus of hernia repair outcomes. This study aims to identify factors which lead to ideal outcomes (asymptomatic and without recurrence) in large umbilical hernias (defect size ≥9 cm2). Review of the prospective International Hernia Mesh Registry was performed. The Carolinas Comfort Scale was used to measure QOL at 1-, 6-, and 12-month follow-up. Demographics, operative details, complications, and QOL data were evaluated using standard statistical methods. Forty-four large umbilical hernia repairs were analyzed. Demographics included: average age 53.6 ± 12.0 and body mass index 34.9 ± 7.2 kg/m2. The mean defect size was 21.7 ± 16.9 cm2, and 72.7 per cent were performed laparoscopically. Complications included hematoma (2.3%), seroma (12.6%), and recurrence (9.1%). Follow-up and ideal outcomes were one month = 28.2 per cent, six months = 42.9 per cent, one year = 55.6 per cent. All patients who remained symptomatic at one and two years were significantly symptomatic before surgery. Symptomatic preoperative activity limitation was a significant predictor of nonideal outcomes at one year ( P = 0.02). Symptomatic preoperative pain was associated with nonideal outcomes at one year, though the difference was not statistically significant ( P = 0.06). Operative technique, mesh choice, and fixation technique did not impact recurrence or QOL. Repair of umbilical hernia with defects ≥9 cm2 had a surprising low rate of ideal outcomes (asymptomatic and no recurrence). All patients with nonideal long-term outcomes had preoperative pain and activity limitations. These data may suggest that umbilical hernia should be repaired when they are small and asymptomatic.

Umbilical hernias: the cost of waiting

BACKGROUND

Umbilical hernias are well described in the literature, but its impact on health care is less understood. The purpose of this study was to investigate the effect of non-operative management of umbilical hernias on cost, work absenteeism, and resource utilization.

METHODS

The Truven Health Database, consisting of 279 employers and over 3000 hospitals, was reviewed for all umbilical hernia patients, aged 18-64 who were enrolled in health plans for 12 months prior to surgery and 12 months after surgery. Patients were excluded if they had a recurrence or had been offered a "no surgery" approach within 1 year of the index date. The remaining patients were separated into surgery (open or laparoscopic repair) or no surgery (NS). Post-cost analysis at 90 and 365 days and estimated days off from work were reviewed for each group.

RESULTS

The non-surgery cohort had a higher proportion of females and comorbidity index. Adjusted analysis showed significantly higher 90 and 365 costs for the surgery group (p < 0.0001), though the cost difference did decrease over time. NS group had significantly higher estimated days of health-care utilization at both the 90 (1.99 vs. 3.58 p < 0.0001) and 365 (8.69 vs. 11.04 p < 0.0001) day post-index mark. A subgroup analysis demonstrated laparoscopic repair had higher costs compared to open primarily due to higher index procedure costs (p < 0.05).

CONCLUSIONS

Though the financial costs were found to be higher in the surgery group, the majority of these were due to the surgery itself. Significantly higher days of health-care utilization and estimated days off work were experienced in the NS group. It is our belief that early operative intervention will lead to decreased costs and resource utilization.

Donor-Site Hernia Repair in Abdominal Flap Breast Reconstruction: A Population-Based Cohort Study of 7929 Patients

BACKGROUND

The authors investigated hernia repair rates following pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) flap breast reconstruction in English National Health Service hospitals.

METHODS

Women diagnosed with breast cancer who underwent pedicled TRAM, free TRAM, or DIEP flap breast reconstruction procedures in English National Health Service hospitals between April of 2006 and March of 2012 were identified using the Hospital Episode Statistics database. Women who underwent mastectomy without reconstruction acted as controls, and hernia repair rates were calculated for all four groups. Multiple Cox regression was performed to estimate the relative risk of hernia repair among the reconstruction groups, adjusted for age, obesity, previous abdominal surgery, reconstruction year, and bilateral flap harvest.

RESULTS

Between 2006 and 2012, 7929 women had a DIEP or TRAM flap breast reconstruction. The overall hernia repair rate within 3 years was 2.45 percent after abdominal flap breast reconstruction, and 0.28 percent among the 15,679 women who had mastectomy only. Mean time to hernia repair following an abdominal flap harvest was 17.7 months. Compared with DIEP flaps, free and pedicled TRAM flap procedures were associated with adjusted hazard ratios of 1.81 (95 percent CI, 1.24 to 2.64) and 2.89 (95 percent CI, 1.91 to 4.37), respectively. The only independent risk factor for hernia repair was age older than 60 years (p = 0.039).

CONCLUSIONS

Abdominally based autologous breast reconstruction carries a small risk of subsequent donor-site hernia repair. The rates herein can be used to inform patients and to assess quality of care across service providers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Current options in umbilical hernia repair in adult patients

Umbilical hernia is a rather common surgical problem. Elective repair after diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh can be placed through either an open or laparoscopic approach with good clinical results. Standard polypropylene mesh is suitable for the open onlay technique; however, composite meshes are required for laparoscopic repairs. Large seromas and surgical site infection are rather common complications that may result in recurrence. Obesity, ascites, and excessive weight gain following repair are obviously potential risk factors. Moreover, smoking may create a risk for recurrence.

Minimal incision scar-less open umbilical hernia repair in adults - technical aspects and short-term results

Background: There is no gold standard technique for umbilical hernia (UH) repair. Conventional open UH repair often produces an undesirable scar. Laparoscopic UH repair requires multiple incisions beyond the umbilicus, specialized equipments, and expensive tissue separating mesh. We describe our technique of open UH repair utilizing a small incision. The technique was derived from our experience with single incision laparoscopy. We report the technical details and short-term results.

Methods: This is a retrospective analysis of the first 20 patients, who underwent minimal incision scar-less open UH repair, from June 2011 to February 2014. A single intra-umbilical curved incision was used to gain access to the hernia sac. Primary suture repair was performed for defects up to 2 cm. Larger defects were repaired using an onlay mesh. In patients with a BMI of 30 kg/m² or greater, onlay mesh hernioplasty was performed irrespective of the defect size.

Results: A total of 20 patients, 12 males and 8 females underwent the procedure. Mean age was 50 (range 29–82) years. Mean BMI was 26.27 (range 20.0–33.1) kg/m². Average size of the incision was 1.96 range (1.5–2.5) cm. Mesh hernioplasty was done in nine patients. Eleven patients underwent primary suture repair alone. There were no postoperative complications associated with this technique. Average postoperative length of hospital stay was 3.9 (range 2–10) days. Mean follow-up was 29.94 months (2 weeks to 2.78 years). On follow-up there was no externally visible scar in any of the patients. There were no recurrences on final follow-up.

Conclusion: This technique provides a similar cosmetic effect as obtained from single port laparoscopy. It is easy to perform, safe, offers good cosmesis, does not require incisions beyond the umbilicus, and cost effective, with encouraging results on short-term follow-up. Further research is needed to assess the true potential of the technique and the long-term results.