Comparison between the short-term results of onlay and sublay mesh placement in the management of uncomplicated para-umbilical hernia: a prospective randomized study

UMBILICAL AND EPIGASTRIC HERNIA REPAIR: A SYSTEMATIC REVIEW

BACKGROUND

Umbilical and epigastric hernias are among the most common hernias of the abdominal wall; however, there is a lack of standardization for their treatment.

AIMS

To clarify the controversies regarding therapeutic possibilities, indications, and surgical techniques for umbilical and epigastric hernia repair.

METHODS

A systematic review and qualitative analysis of randomized clinical trials published in the last 20 years, involving adults (aged 18 years and over) with umbilical and/or epigastric hernias, was performed by systematically searching the PubMed/Medline, Cochrane, SciELO, and LILACS databases. The risk of bias in individual studies was assessed using the Cochrane Risk of Bias Tool.

RESULTS

Initially, 492 studies were selected and, subsequently, 15 randomized controlled clinical trials were chosen that met the inclusion criteria and underwent full reading and qualitative analysis, considering possible bias.

CONCLUSIONS

This review concluded that it is evident the superiority of the use of meshes in the repair of epigastric/primary umbilical hernias with a defect larger than 1 cm, even in certain emergency situations. However, suture repair is a good option for patients with a defect smaller than 1 cm. In the laparoscopic approach, recent evidence points towards possible superiority in fixation with fibrin sealant, and fascial defect closure is recommended. In addition, due to a scarcity of randomized controlled trials with low risk of bias, further studies are needed on types, positioning and fixation techniques, as well as the real role of video-assisted laparoscopic surgery in the correction of hernias, especially umbilical.

Ventral Hernia Repair: Does Mesh Position Matter?

Mesh positioning is a commonly discussed detail in ventral hernia repair and is often cited as a major contributor to the outcome of the operation. However, there is a paucity of data that establishes one plane as superior to others. In this article, we will provide an overview of all potential planes to place prosthetic material and review the relevant literature supporting each option and the complications associated with accessing each anatomic plane.

Short-term complications after onlay versus preperitoneal mesh repair of umbilical hernias: a prospective randomized double-blind trial

PURPOSE

To compare the incidence of surgical site occurrences (SSOs) following onlay versus preperitoneal mesh placement in elective open umbilical hernia repairs.

METHODS

This study presents a secondary analysis of a randomized double-blind trial conducted on female patients with primary umbilical hernias admitted to a general hospital, in a residency training program setting. Fifty-six subjects were randomly assigned to either onlay (n=30) or preperitoneal (n=26) mesh repair group. Data on baseline demographics, past medical history, perioperative details, postoperative pain (visual analogue scale (VAS)), wound-related complications, and recurrence were assessed using a standardized protocol.

RESULTS

No statistically significant differences were observed between groups regarding patients' demographics, comorbidities, or defect size. Operative time averaged 67.5 (28-110) min for onlay and 50.5 (31-90) min for preperitoneal repairs, p=.03. The overall rate of SSOs was 21.4% (n=12), mainly in the onlay group (33% vs 7.7%; p=0.02, 95% CI 0.03-0.85) and mostly due to seromas. There were no between-group significant differences in postoperative VAS scores at all timepoints. After a maximum follow-up of 48 months, one recurrence was reported in the onlay group. By logistic regression, the onlay technique was the only independent risk factor for SSOs.

CONCLUSION

The presented data identified a decreased wound morbidity in preperitoneal umbilical hernia repairs, thus contributing to the limited body of evidence regarding mesh place selection in future guidelines. Further cases from this ongoing study and completion of follow-up are expected to also compare both techniques in terms of long-term outcomes.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ReBEC) UTN code: U1111-1205-0065 (date of registration: March 27, 2018).

Favourable outcomes after Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Non-Complex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-Analysis

OBJECTIVE

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

SUMMARY BACKGROUND DATA

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For non-complex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

METHODS

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

RESULTS

Ninety-three studies representing 12440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% (95%CI: 2.2-4.2%, n = 11049) after minimally 12 months and 4.1%, (95%CI: 2.9-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2-6.4%, n = 4891) and 5.5% (95%CI: 4.4-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (OR: 0.27, 95%CI: 0.15-0.51, p < 0.001) and equal recurrence rates compared to intraperitoneal onlay (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03-3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8-2.8%, n = 982), albeit based on non-randomized studies.

CONCLUSIONS

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except surgical site infection. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

Association between surgical hernia repair techniques and the incidence of seroma: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Ventral hernia repair (VHR) includes the surgical reconstruction of the abdominal wall (AW) using different surgical techniques. Although such procedures are usually devoid of complications, the formation of seroma may frequently occur. We performed a systematic review to assess the evidence from randomized controlled trials (RCTs) comparing VHR techniques and their impact on seroma formation.

METHODS

We included RCTs having seroma formation as primary endpoint. We included patients of both sexes (age > 18). For data synthesis we applied a random-effects model and calculated risk ratios (RR) with 95% confidence intervals (CI) using the Mantel-Haenszel method. Risk of bias (ROB) and publication bias were evaluated following Cochrane recommendations.

RESULTS

After database search and article screening, 21 records were included in this review. Ten RCTs compared onlay vs. sublay mesh placement techniques. Pooled analysis showed a significantly higher risk ratio for seroma in the onlay cohort (RR = 2.61, 95% CI 1.86-3.66, I² = 0, GRADE quality of evidence, moderate). Five RCTs compared laparoscopic intraperitoneal onlay mesh repair vs. open mesh placement. Pooled analysis showed that seroma formation did not differ significantly between groups (RR = 1.91, 95% CI 0.69-5.28, I² = 66%, GRADE quality of evidence, poor). High ROB was found in all studies and significant publication bias was detected in both meta-analyses.

CONCLUSION

Compared to sublay ventral hernia repair, the onlay procedure is associated with a significantly higher risk of seroma. No significant differences were observed when laparoscopic VHR was compared with the open surgical procedure. Due to the diversity of surgical techniques reported in included RCTs, it is currently not possible to draw conclusive clinical recommendations. Future studies should be standardized to provide detailed data allowing thorough evaluation of the impact of the evidence on clinical practice.

The Case for Onlay Biologic Mesh in Abdominal Wall Reconstruction Using Progressive Tension Suture Fixation

BACKGROUND

After many years of debate, underlay and sublay placement of mesh slowly emerged as the standard of care in abdominal wall reconstruction because of lower hernia recurrence rates. However, onlay has the advantages of being faster, less invasive, and technically easier compared with underlay and sublay. Therefore, if a similar recurrence could be achieved, then onlay should be a consideration. In this study, we present a new onlay method using multipoint progressive tension suture fixation.

METHODS

This was a retrospective chart review of patients who underwent abdominal wall reconstruction from 2012 to 2019. Inclusion criteria included onlay mesh placement and at least 1 year of follow-up. The core principles of the surgical technique are establishing myofascial continuity by component separation and reinforcing the repair with onlay mesh that is fixated with multipoint progressive tension sutures.

RESULTS

The number of patients after exclusions was 59, and the average body mass index was 32.52 ± 6.44 kg/m2. More than half (62.7%) of patients had a history of hypertension, 95% had at least 1 prior abdominal/pelvic surgery, and 61% had at least 1 prior hernia repair. Postoperative complications included 20.3% of patients requiring drainage of a fluid collection in the clinic setting, and 29.3% of patients requiring return to the operating room for any reason (including superficial wound debridement). The average defect size was 231.88 ± 195.86 cm2, the mean follow-up was 3.11 ± 1.83 years, and the recurrence rate was 5.1%.

CONCLUSIONS

We report a hernia recurrence rate of 5.1% in a high-risk population with complex defects at a mean of 3.1 years of follow-up using onlay mesh fixated with multipoint progressive tension sutures. This recurrence rate is similar to that reported for both underlay and sublay techniques. However, the onlay approach is technically easier, faster, and less invasive compared with underlay and sublay techniques, which may translate into wider reproducibility, lower costs, and improved patient safety.

Trocar umbilical hernia repair by open suture repair and open suture-mesh repair in an ambulatory setting in comparison to recurrent and primary umbilical hernia repair

Reports on the ambulatory open repair of umbilical trocal hernias are missing. Patients with trocar, primary and recurrent umbilical hernia open suture and open suture–mesh repair with prospective follow-up were retrospectively evaluated. Patients received perioperative antibiotic prophylaxis, preemptive analgesia and modified anesthesia. In total, 171 patients with umbilical hernia (51 years, female 14%; male 86%) were treated with open suture (n = 29; 17%) and suture–mesh (n = 142; 83%) repair. In total, 10% of patients were treated for trocar hernia (late onset), 5% for recurrent hernia and 85% for a primary umbilical hernia. In total, 29% of trocar hernia repairs had minor complications associated with obesity (40%) and comorbidity (80%). Age, suture and suture–mesh repair were not associated with complications. According to guidelines for umbilical hernia repair open flat mesh may be useful in the treatment of trocar 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.

Mechanical Properties of Polypropylene Warp-Knitted Hernia Repair Mesh with Different Pull Densities

The medical polypropylene monofilament with a diameter of 0.10 mm was used as the material. Four different pull densities and two different warp run-ins were set up on the electronic traverse high-speed Tricot warp knitting machine, with the gauge of E28. The raw material was used to knit four variations of single bar plain knitted fabrics with 1 in-1 miss setting. Each variation required eight samples. The mechanical properties of the above 32 warp-knitted fabric samples are tested, including their tensile stress (in both vertical and horizontal directions), tearing stress (in both vertical and horizontal directions) and bursting stress. The results obtained shows that the relationship between the vertical, the horizontal stress, and the pull density are not monotonic. The tensile stress in the vertical direction firstly decreases and then increases with an increase of the pull density; however, the tensile stress in the horizontal direction firstly increases and then slightly decreases with an increase of the pull density; again the vertical tensile stress of all fabrics was always higher than the horizontal tensile stress. The bursting stress has a positive linear relation to the pull density. The vertical tearing stresses of four samples were greater than the horizontal tearing stress.

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.

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

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

Importance of mesh overlap on hernia recurrence after open umbilical hernia repair with bilayer prosthesis

BACKGROUND

importance of mesh overlap on recurrence after open umbilical hernia repair has been poorly studied.

METHODS

a retrospective cohort study was performed with patients who underwent open umbilical hernia repair with bilayer prosthesis between 2004 and 2015.

RESULTS

1538 patients were included. Fifty patients (3.3%) had a mesh overlap lower than 1 cm. After a mean follow-up of 4.1 years 53 patients (3.5%) developed a recurrence. Recurrence was associated with a mesh overlap smaller than 1 cm (10.2% vs. 3.3%, p = 0.010, OR = 3.3). In the logistic regression model an overlap smaller than 1 cm was not statistically associated with recurrence (OR = 2.5, p = 0.123). Female gender, postoperative complications and prosthesis size were associated with hernia recurrence.

CONCLUSIONS

mesh overlap seems to be an important factor for hernia recurrence. A mesh overlap of at least 1 cm should be used until more studies are performed about this issue.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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