Hybrid ventral hernia repair: technique and results

Comparative effectiveness of hybrid and laparoscopic techniques for repairing complex incisional ventral hernias: a systematic review and meta-analysis

BACKGROUND

The recently developed Hybrid Hernia Repair technique (HHR), an adaptation of the laparoscopic method, has been proposed as a potential alternative for the treatment of complex Incisional Ventral Hernias (IVH). While single-arm studies have reported promising outcomes, a comprehensive meta-analysis affirming these benefits is lacking. This meta-analysis aims to compare the clinical outcomes of HHR and Laparoscopic Hernia Repair (LHR) in the management of IVH.

METHODS

An exhaustive search of the literature was conducted, targeting publications in both English and Chinese that compare HHR and LHR up to March 31, 2023. The primary outcomes examined were operation time, blood loss, and intestinal injury. Secondary outcomes included rates of seroma, wound infection, post-operative acute/chronic pain, recurrence, and mesh bulging. The RevMan 5.0 software facilitated the statistical meta-analysis.

RESULTS

The final analysis incorporated data from 14 studies, encompassing a total of 1158 patients, with 555 undergoing HHR and 603 treated with LHR. Follow-up data, ranging from 12 to 88 months, were available in 12 out of the 14 identified studies. The HHR method was associated with a significantly lower risk of seroma (OR = 0.29, P = 0.0004), but a higher risk of wound infection (OR = 2.10, P = 0.04). No significant differences were observed between the two techniques regarding operation time, blood loss, intestinal injury, intestinal obstruction, post-operative pain, mesh bulging, and recurrence.

CONCLUSIONS

The HHR technique did not demonstrate a clear advantage over LHR in reducing surgical complications, apart from a lower incidence of postoperative seroma. Surgeons with substantial expertise may choose to avoid incidental conversion or intentional hybrid procedures. Further research is needed to clarify the optimal surgical approach for IVH.

eTEP-RS for incisional hernias in a non-robotic center. Is laparoscopy enough to perform a durable MIS repair of the abdominal wall defect?

INTRODUCTION

Incisional hernias can complicate up to 25% of laparotomies, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced. The method was presented relatively recently and continues to evolve. The use of a robotic platform in eTEP-RS resulted in a significant improvement in ergonomics. Therefore, the questions arise as to whether the laparoscopic technique might still be feasible for such long procedures. The objective of this study is to present our early results in the treatment of patients with incisional ventral hernias using eTEP-RS and to discuss key technical aspects.

PATIENTS AND METHODS

A prospective case-controlled study was conducted for all incisional ventral hernia patients (hernia orifice between 4 and 10 cm) who underwent eTEP-RS between March 2019 and December 2021. Demographic data were recorded; and perioperative and postoperative results were analyzed.

RESULTS

We performed 34 eTEP-RS procedures. The mean duration of the surgery was 211 min (145-295). The mean width of the defect was 6.8 cm and the defect area was 42.5 cm². The mean mesh size was 498 cm² (270-625). After an average follow-up of 16 months (2-30), there was no recurrence or major complication.

CONCLUSIONS

The eTEP-RS is a safe alternative to open ventral hernia repair in selected cases and allows for the placement of a large piece of mesh in accordance with current recommendations, even in non-robotic centers. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair. Compliance with certain rules of the laparoscopic eTEP-RS facilitates improved ergonomics for this procedure even in non-robotic centers.

Outcomes and complications of open, laparoscopic, and hybrid giant ventral hernia repair

BACKGROUND

An incisional hernia is a common complication of abdominal surgery.

AIM

To evaluate the outcomes and complications of hybrid application of open and laparoscopic approaches in giant ventral hernia repair.

METHODS

Medical records of patients who underwent open, laparoscopic, or hybrid surgery for a giant ventral hernia from 2006 to 2013 were retrospectively reviewed. The hernia recurrence rate and intra- and postoperative complications were calculated and recorded.

RESULTS

Open, laparoscopic, and hybrid approaches were performed in 82, 94, and 132 patients, respectively. The mean hernia diameter was 13.11 ± 3.4 cm. The incidence of hernia recurrence in the hybrid procedure group was 1.3%, with a mean follow-up of 41 mo. This finding was significantly lower than that in the laparoscopic (12.3%) or open procedure groups (8.5%; P < 0.05). The incidence of intraoperative intestinal injury was 6.1%, 4.1%, and 1.5% in the open, laparoscopic, and hybrid procedures, respectively (hybrid vs open and laparoscopic procedures; P < 0.05). The proportion of postoperative intestinal fistula formation in the open, laparoscopic, and hybrid approach groups was 2.4%, 6.8%, and 3.3%, respectively (P > 0.05).

CONCLUSION

A hybrid application of open and laparoscopic approaches was more effective and safer for repairing a giant ventral hernia than a single open or laparoscopic procedure.

Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature

With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.

Hybrid versus open retromuscular abdominal wall repair: early outcomes

BACKGROUND

The hybrid approach to abdominal wall reconstruction (AWR) for abdominal wall hernias combines minimally invasive posterior component separation and retromuscular dissection with open fascial closure and mesh implantation. This combination may enhance patient outcomes and recovery compared to the open approach alone. The purpose of this study is to evaluate the operative outcomes of hybrid vs. open abdominal wall reconstruction.

METHODS

A retrospective review was conducted to compare patients who underwent open versus hybrid AWR between September 2015 and August of 2018 at Anne Arundel Medical Center. Patient demographics and perioperative data were collected and analyzed using univariate analysis.

RESULTS

Sixty-five patients were included in the final analysis: 10 in the hybrid and 55 in the open groups. Mean age was higher in the hybrid vs. open group (65.1 vs. 56.2 years, p < 0.05). The hybrid and open groups were statistically similar (p > 0.05) in gender distribution, mean BMI, and ASA score. Intraoperative comparison found hybrid patients parallel to open patients (p > 0.05) in mean operative time (294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area, and drain placement. The mean total hospital cost was lower in the hybrid group compared to the open group ($16,426 vs. $19,054, p = 0.43). The hybrid group had a shorter length of stay (5.3 vs. 3.6 days, p = 0.03) after surgery and was followed for a similar length of time (12.3 vs. 12.6 months, p = 0.91). The hybrid group showed a lower trend of seroma, hematoma, wound infection, ileus, and readmission rates after surgery.

CONCLUSION

A review of patient outcomes after hybrid AWR highlights a trend towards shorter length of stay, lower hospital cost, and fewer complications without significant addition to operative time. Long-term studies on a larger number of patients are definitively needed to characterize the comprehensive benefits of this approach.

A new three-step hybrid approach is a safe procedure for incisional hernia: early experiences with a single centre retrospective cohort

Purpose

In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh.

Objectives

To evaluate first perioperative outcomes with this technique.

Methods

From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤ 10 cm underwent a elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed.

Results

Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks.

Conclusion

A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.

Hybrid: Evolving techniques in laparoscopic ventral hernia mesh repair

Introduction

Laparoscopic repair is now the treatment of choice for most cases of ventral/incisional hernia. Although the technique has undergone many refinements, there is no standard technique for difficult or complicated hernias.

Aim

The aim of this study was to show the different innovative methods used to treat difficult ventral hernia through hybrid techniques.

Materials and Methods

A total of 75 (n = 75) patients underwent Laparoscopic Ventral Hernia Hybrid Mesh Repair (LVHHMR) by our surgical unit between January 2014 and December 2016. Three different techniques of repairing the defects were used. Mesh fixation time, post-operative pain score (visual analogue score) and follow-up for pain and recurrence (at 6 months, 12 months and 24 months) were recorded and analysed.

Results

Out of 75 patients (20 men and 55 women), the median age was 45 years and body mass index of the patients was 25-35. Types of hernias operated were paraumbilical hernias, incisional and recurrent hernias. The techniques used were (1) laparoscopic adhesiolysis, open sac excision with closure of defect and laparoscopic mesh placement, (2) laparoscopic adhesiolysis, omphalectomy with closure of defect and laparoscopic mesh placement and (3) open adhesiolysis, sac excision with closure of defect and laparoscopic mesh placement. Five patients required analgesics for 48 h. No patients complained of pain at follow-ups (1 month, 6 months, 12 months and 24 months). Mean hospital stay postoperatively was 2-3 days.

Conclusion

LVHHMR is safe and feasible approach for complicated/difficult ventral hernias. However, further larger studies are required to establish these methods as gold standard.

Laparoscopic management of recurrent ventral hernia: an experience of 222 patients

BACKGROUND

To evaluate the predisposing factors and characteristics of recurrent ventral hernia (RVH) along with the feasibility and outcome of laparoscopy in managing RVH.

METHODS

This study is a retrospective analysis of all patients with reducible or irreducible, uncomplicated RVH who underwent surgical management from January 2012 to June 2018.

RESULTS

Out of 222 patients, 186 (83.8%) were female, and 36 (16.2%) were male. The mean age was 54.1 ± 10.1 years; an average body mass index was 31 kg/m² (19-47.9). The most common previous abdominal operations among female patients were cesarean sections (43.5%) and abdominal hysterectomy (36.6%). Most of the patients had a history of open mesh repair (43.7%) and open anatomical repair (36.9%). The median time of recurrence was 4 years (1-33 years). The median defect size was 10 cm² (range 2-150 cm²), and 73% defects were in the midline. Total 181 of 222 (81.6%) patients underwent laparoscopic intraperitoneal onlay mesh plus (L-IPOM+), 19 (8.5%) laparoscopic-assisted IPOM+, 17(7.7%) laparoscopic anatomical repair, while remaining 5 (2.3%) patients required open mesh reconstruction. The median size of the composite mesh used was 300 cm² (150-600 cm²). The mean operating time was 145 (30-330) min, and median blood loss was 15 (5-110) ml. The median hospital stay was 3 days, and median follow-up period was 37 months. The post-operative symptomatic seroma rate was 3.1%, and re-recurrence rate was 1.4%.

CONCLUSION

Obesity, old age, female sex, previous lower abdominal surgeries, and previous open repair of a hernia are factors associated with recurrence. Laparoscopic repair is feasible with excellent outcome in most of the patients.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results

PURPOSE

The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR.

METHODS

This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain.

RESULTS

Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm³, p = 0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019).

CONCLUSION

Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions.

CLINICAL TRIAL NUMBER

NCT02542085.

[Hybrid repair of postoperative ventral hernia]

AIM

To develop new technique of abdominal wall repair for postoperative ventral hernia without disadvantages which are intrinsic for open and laparoscopic surgery.

MATERIAL AND METHODS

Combined open and laparoscopic hernia repair was used in 18 patients with postoperative ventral hernia. Open stage provided safe dissection of abdominal adhesions and defect closure by autoplasty, laparoscopic procedure consisted of prosthesis deployment without separation of abdominal wall layers. Two types of composite endoprostheses with anti-adhesive coating were used for abdominal wall repair.

RESULTS

There were no cases of recurrence or infectious complications in long-term period (from 3 to 106 months).

CONCLUSION

Hybrid repair of postoperative ventral hernia is safe and effective procedure. Further studies are necessary to assess cost-effectiveness ratio of this method in view of expensive composite endoprostheses and laparoscopic supplies.

Hybrid technique for postoperative ventral hernias - own experience

INTRODUCTION

There are many techniques which may be involved in abdominal hernia repair, from classical to tension-free. Treatment of complicated hernias has undergone evolution. Many surgeons consider the laparoscopic method as a method of choice for incisional hernia repair. Sometimes miniinvasive repair of complicated hernia is not so easy to perform. We are convinced that selected patients may benefit from combined open and laparoscopic techniques.

AIM

To present the operating technique and early results of treatment of 15 patients operated on using the 3 hybrid technique.

MATERIAL AND METHODS

Fifteen patients suffering from recurrent incisional hernias underwent the hybrid technique for their repair between June 2012 and April 2015. The hybrid technique was performed using synthetic meshes in 14 cases and a biological implant in 1 case.

RESULTS

The early postoperative period was uncomplicated in all cases. Within a maximum follow-up period of 32 months, two deep wound infections were observed.

CONCLUSIONS

The hybrid technique may be used in patients with recurrent incisional hernias.

Long-term outcomes of 1326 laparoscopic incisional and ventral hernia repair with the routine suturing concept: a single institution experience

PURPOSE

This retrospective chart analysis reports and assesses the long-term (beyond 10 years) safety and efficiency of a single institution's experience in 1326 laparoscopic incisional and ventral hernia repairs (LIVHR), defending the principle of the suturing defect (augmentation repair concept) prior to laparoscopic reinforcement with a composite mesh (IPOM Plus). This study aims to prove the feasibility and validity of IPOM Plus repair, among other concepts, as a well-justified treatment of incisional or ventral hernias, rendering a good long-term outcome result.

METHODS

A single institution's systematic retrospective review of 1326 LIVHR was conducted between the years 2000 and 2014. A standardized technique of routine closure of the defect prior to the intraperitoneal onlay mesh (IPOM) reinforcement was performed in all patients. The standardized technique of "defect closure" by laparoscopy approximating the linea alba under physiological tension was assigned by either the transparietal U reverse interrupted stitches or the extracorporeal closure in larger defects. All patients benefited from the implant Parietex composite mesh through an Intraperitoneal Onlay Mesh placement with transfacial suturing.

RESULTS

LIVHR was performed on 1326 patients, 52.57% female and 47.43% male. The majority of our patients were young (mean age 52.19 years) and obese (average BMI 32.57 kg/m2). The mean operating time was 70 min and hospital stay 2 days, with a mean follow-up of 78 months. On the overall early complications of 5.78%, we achieved over time the elimination of the dead space by routine closure of the defect, thus reducing seroma formation to 2.56%, with a low risk of infection <1%. Post-op sepsis occurred in only nine cases. Three secondary serosal breakdowns and two late perforations were re-operated, and three diabetic patients had infected hematomas, necessitating mesh removal. Through technical improvement in the suturing concept and our growing experience, we managed to reduce the incidence of transient pain to a low acceptable rate of 3.24% (VAS 5-7) that decreased to 2.56% on a chronic pain stage, which is comparable to the literature. On the overall rate of late complications of 10.74%, we noticed also that by reducing the dead space, the chronic pain, skin bulging, and rate of recurrence were reduced to, respectively, 2.56, 1.50, and 4.72%. One case of mortality was due to a tracheal stenosis, responsible for an acute respiratory syndrome. On a second-look follow-up of 126 patients (9.5%), 45.23% were adhesion free, 42.06% had minor adhesions classified as Müller I, and 12.69% had serosal adhesions classified as Müller II.

CONCLUSION

Our long series confirms the unexpected high rate of feasibility in the suturing concept or augmentation technique, and confers additional benefits to the conventional advantages of LIVHR in terms of reducing the overall morbidity, with a low rate of recurrences. Based on our experience and study, the current best indications for a successful LIVHR procedure should be tailored upon the limitations of the defect's width and proper patient selection, to restore adequately the optimal functionality of the abdominal muscles and provide better functional and cosmetic outcomes.