A systematic review of the surgical treatment of large incisional hernia

The effect of preoperative botulinum toxin a injection on traction force during hernia repair: a prospective, single-blind study, intra-patient comparison using contralateral side as a control

PURPOSE

Ventral hernias are a common complication of laparotomy, posing challenges particularly when primary fascial closure is unattainable. Although chemical component separation using preoperative botulinum toxin A (BTX) injections has emerged as a promising adjunct, objective evidence of its efficacy remains limited. This study aimed to objectively assess the effect of preoperative BTX on traction force during ventral hernia repair.

METHODS

A prospective, single-blind study was conducted on patients with midline incisional hernias following liver transplantation. BTX was administered unilaterally, and the traction force required to medially advance the anterior rectus sheath was measured intraoperatively. Pre- and post-injection CT scans were analyzed for changes in hernia size and LAW muscle measurements. Statistical analyses were performed to evaluate traction force differences between BTX-injected and uninjected sides.

RESULTS

Ten patients underwent hernia repair with primary fascial closure achieved in all cases. Comparison of pre- and post-injection CT scans showed no significant changes in hernia size. LAW muscle length increased by 1.8 cm, while thickness decreased by 0.2 cm. Intraoperative traction force measurements revealed a significant reduction on the BTX-injected side compared to the uninjected side (p < 0.0001). The traction force ratio on the BTX-injected to the uninjected side averaged 57%, indicating the efficacy of BTX in reducing tension.

CONCLUSION

Preoperative BTX significantly reduces traction force during ventral hernia repair, highlighting its potential as an adjunctive therapy in complex cases. While challenges remain in patient selection and outcome assessment, BTX offers a promising avenue for enhancing abdominal wall reconstruction outcomes and reducing surgical complications.

Open IPOMs for medium/large incisional ventral hernia repairs in the French Hernia Registry: factors associated with their use and mesh-related outcomes

PURPOSE

The use of open intra-peritoneal onlay mesh repairs (O-IPOMs) for treating medium/large incisional ventral hernias has come into question due to the development of minimally invasive and sublay procedures. This study aimed to identify factors that are associated with the use of O-IPOMs in France.

METHODS

We analysed prospectively collected data from the French Hernia Registry on incisional ventral hernia repairs (IVHR) for hernias ≥ 4 cm in width.

RESULTS

We obtained data for 2261 IVHR (from 11/09/2011 to 30/03/2020): 733 O-IPOMs and 1,528 other techniques. We found that the O-IPOMs were performed on patients with more patient-related risk factors compared with the other techniques. Specifically, there was a higher proportion of patients with ASA III/IV (40.47% vs. 28.02%; p < 0.00001) and at least one patient-related risk factor (66.17% vs. 58.51%; p = 0.0005). Of the 733 O-IPOMs, 195 used Ventrio ST™ (VST), the most commonly used mesh for such IPOMs in our database; the other 538 O-IPOMs used other meshes (OM). The VST subgroup had a higher proportion of patients with ASA III/IV (52.58% vs. 36.07%; p < 0.0001) and on anticoagulants (26.04% vs. 18.41%; p = 0.0229) compared with the OM subgroup; they also had a lower recurrence rate after 2 years (5.83% vs. 15.41%; p = 0.008). However, large (≥ 10 cm) or lateral defects were more common in the OM subgroup, and their mesh/defect area ratio was lower.

CONCLUSION

O-IPOMs were performed on patients with more comorbidities and/or complex incisional hernias compared with other techniques.

Open intraperitoneal onlay mesh repair with anterior component separation as a bail-out procedure in the management of complex hernias

PURPOSE

Surgical repair of complex abdominal wall hernias remains technically demanding and is widely recognized as a risk factor for unfavorable outcomes with high recurrence and morbidity rates. The objective is to assess short- and long-term complications after open intraperitoneal onlay mesh (IPOM) repair combined with bilateral anterior component separation (ACS) for large and difficult incisional hernias, alongside evaluating hernia recurrence rates.

METHODS

This retrospective analysis utilized data sourced from Hospital electronic health records and a prospective database at an academic tertiary referral center. Data collection was carried out from patients operated between January 2006 and December 2017. Eligible patients had complex incisional hernias measuring at least 10 cm in their transverse diameter and had an open IPOM repair with bilateral ACS.

RESULTS

In our study group of 45 patients, the 30-day surgical site occurrence (SSO) rate was high (37.8%), primarily consisting of superficial postoperative complications as seroma (17.8%) and wound dehiscence (6.7%). Among six patients (13.3%), wound complications escalated to chronic infected mesh-related problems, leading to complete mesh removal in four cases (8.9%) and partial mesh removal in two cases (4.4%). Regarding long-term complications, five patients (11.1%) developed enterocutaneous fistula. The recurrence rate was modest [5 out of 41 (12.2%)] over a median follow-up period of 99 months.

CONCLUSIONS

Despite a high SSO rate, application of the open IPOM technique with ACS could serve as a valuable rescue option for managing large and complex hernias, with acceptable hernia recurrence rates at long-term follow-up.

Botulinum toxin A in complex incisional hernia repair: a systematic review

PURPOSE

To evaluate the safety, efficacy, and short and long-term postoperative results of using BTA.

METHODS

We conducted a systematic review following the recommendations of the PRISMA method. We systematically reviewed the MEDLINE/PubMed and SCOPUS electronic databases for studies published between January 2010 and September 2021. This systematic review was registered in PROSPERO, with registration number CRD42021252445.

RESULTS

After applying the selection criteria, 11 relevant articles were selected. The total sample size was 1058 patients. Most studies aimed to assess the rate of fascial closure, followed by the rate of recurrence and reporting of postoperative complications, as well as the need for the components separation technique (CST). None of the studies reported serious complications from using BTA. Regarding fascial closure, all articles had rates above 75%, except for one. Surgical site events ranged between 19% and 29.4%. No recurrence in the group that used BTA was recorded in five studies. The other articles reported recurrence rates ranging from 6.4 to 11.4% in the groups that received BTA. The studies had varying follow-up times ranging from 1 to 49 months, with a mean of 18.6 months (± 11.2).

CONCLUSION

This review described most of the key points about the preoperative use of BTA in hernia repair. It can be concluded that the use of BTA is a safe and effective practice that promotes good short and long-term results. However, the limitations of the current literature prevent more accurate conclusions on the subject.

Hospital costs of robotic-assisted and open treatment of large ventral hernias

Robotic-assisted treatment of ventral hernia offers many advantages, however, studies reported higher costs for robotic surgery compared to other surgical techniques. We aimed at comparing hospital costs in patients undergoing large ventral hernia repair with either robotic or open surgery. We searched from a prospectively maintained database patients who underwent robotic or open surgery for the treatment of the large ventral hernias from January 2016 to December 2022. The primary endpoint was to assess costs in both groups. For eligible patients, data was extracted and analyzed using a propensity score-matching. Sixty-seven patients were retrieved from our database. Thirty-four underwent robotic-assisted surgery and 33 open surgery. Mean age was 66.4 ± 4.1 years, 50% of patients were male. After a propensity score-matching, a similar total cost of EUR 18,297 ± 8,435 vs. 18,024 ± 7514 (p = 0.913) in robotic-assisted and open surgery groups was noted. Direct and indirect costs were similar in both groups. Robotic surgery showed higher operatory theatre-related costs (EUR 7532 ± 2,091 vs. 3351 ± 1872, p < 0.001), which were compensated by shorter hospital stay-related costs (EUR 4265 ± 4366 vs. 7373 ± 4698, p = 0.032). In the treatment of large ventral hernia, robotic surgery had higher operatory theatre-related costs, however, they were fully compensated by shorter hospital stays and resulting in similar total costs.

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction

BACKGROUND

Patients often need admission at an Intensive Care Unit (ICU), immediately after complex abdominal wall reconstruction (CAWR). Lack of ICU resources requires adequate patient selection for a planned postoperative ICU admission. Risk stratification tools like Fischer score and Hernia Patient Wound (HPW) classification may improve patient selection. This study evaluates the decision-making process in a multidisciplinary team (MDT) on justified ICU admissions for patients after CAWR.

METHODS

A pre-Covid-19 pandemic cohort of patients, discussed in a MDT and subsequently underwent CAWR between 2016 and 2019, was analyzed. A justified ICU admission was defined by any intervention within the first 24 h postoperatively, considered not suitable for a nursing ward. The Fischer score predicts postoperative respiratory failure by eight parameters and a high score (> 2) warrants ICU admission. The HPW classification ranks complexity of hernia (size), patient (comorbidities) and wound (infected surgical field) in four stages, with increasing risk for postoperative complications. Stages II-IV point to ICU admission. Accuracy of the MDT decision and (modifications of) risk-stratification tools on justified ICU admissions were analyzed by backward stepwise multivariate logistic regression analysis.

RESULTS

Pre-operatively, the MDT decided a planned ICU admission in 38% of all 232 CAWR patients. Intra-operative events changed the MDT decision in 15% of all CAWR patients. MDT overestimated ICU need in 45% of ICU planned patients and underestimated in 10% of nursing ward planned patients. Ultimately, 42% went to the ICU and 27% of all 232 CAWR patients were justified ICU patients. MDT accuracy was higher than the Fischer score, HPW classification or any modification of these risk stratification tools.

CONCLUSION

A MDT's decision for a planned ICU admission after complex abdominal wall reconstruction was more accurate than any of the other risk-stratifying tools. Fifteen percent of the patients experienced unexpected operative events that changed the MDT decision. This study demonstrated the added value of a MDT in the care pathway of patients with complex abdominal wall hernias.

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study

BACKGROUND

Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study.

METHODS

A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated.

RESULTS

Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm² vs botulinum toxin A 289.7 ± 162.4 cm²; P = .73) (mean volume: 1,498.3 + 2,043.4 cm³ vs 2,914.7 + 6,539.4 cm³; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13).

CONCLUSION

In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

State-of-the-art abdominal wall reconstruction and closure

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

Skin closure following abdominal wall reconstruction: three-layer skin suture versus staples

Skin closure following abdominal wall reconstruction (AWR) has received little attention, even though these patients have demonstrated insufficient wound healing. This study assessed the postoperative wound-related complications and patient-reported outcomes after skin closure using single- or triple layer closure following AWR. This was a retrospective study at a University Hospital from 2016 to 2018. Patients were grouped into a single-layer cohort (SLC) and a triple-layer cohort (TLC). Skin incisions closed with either technique were compared. Postoperative complications were registered from chart review (SLC: n = 48, TLC: n = 40). Patient reported-outcomes were assessed through the Patient Scar Assessment Questionnaire (PSAQ) and the Hernia Related Quality of Life survey. A total of 51 patients were included (SLC: n = 26, TLC: n = 25). There was no difference in wound complications after single- or triple-layer skin closure; seroma (SLC: 16.7% vs. TLC: 15%, p = 1.00), surgical site infection (SLC: 4.2% vs. TLC: 7.5%, p = .834), hematoma (SLC: 6.2% vs. TLC: 2.5%, p = .744) and wound rupture (SLC: 2.1% vs. TLC: 2.5%, p = 1.00). Patients who had incisions closed using single-layer closure were more satisfied; PSAQ satisfaction with scar symptoms (SLC: 6.7 points (IQR 0.0-18.3) vs. TLC: 26.7 points (IQR 0.0-33.3), p = .039) and scar aesthetics (SLC 25.9 points (IQR 18.5-33.3) vs. TLC: 37.0 (IQR 29.6-44.4), p = .013). There was no difference in 30-day wound complications after either skin closure technique. The results favoured the single-layer closure technique regarding the cosmetic outcome.Abbreviations: AWR: abdominal wall reconstruction; SLC: single-layer cohort; TLC: triple-layer cohort; PSAQ: patient scar assessment questionnaire; IH: incisional hernia; QOL: quality of life; BMI: body mass index; HerQLes: hernia-related quality of life; ASA: American Society of Anesthesiologists; SSO: surgical site occurence; SSI: surgical site infection; LOS: length of stay; RCT: randomized controlled trial.

Comparison of Surgical Treatment Results of Large Incisional Hernias

Introduction Incisional hernias are one of the most common complications after abdominal surgery. Surgical repairs of large incisional hernias have higher complications and recurrence rates compared to smaller incisional hernia repairs. For this reason, it is a more difficult and experience-requiring application for surgeons. In addition, there is no evidence-based consensus in the literature regarding the optimal surgical treatment of large incisional hernias. The aim of this study is to compare the results of the three most common surgical treatment methods used in a tertiary university hospital for the repair of large incisional hernias in terms of patients' characteristics, recurrence, and complication rates of the treatment methods. Methods Between 2014 and 2020, 366 patients with incisional hernias with facial defects larger than 10 cm in a tertiary medical faculty hospital located in eastern Turkey were analyzed. Patients were divided into three groups according to the surgical method used: open onlay prolene mesh (OPM) method, laparoscopic intraperitoneal sublay dual mesh (IPSDM) method, and open IPSDM method. Postoperative complications were divided into five groups as follows: wound complications, complications due to surgical procedures, medical complications, recurrences, and mortality. Treatment methods were compared according to the demographic characteristics of the patients and the postoperative complication rates. Results Of the patients, 141 were male and 225 were female, and the mean age was 58.0 ± 28 years. Of the patients, 81.9% were operated on with the open OPM, 10.9% with the laparoscopic IPSDM, and 7.1% with the open IPSDM. Wound complications occurred in 26.7% of patients, surgical complications in 3.2%, medical complications in 6.5%, recurrence in 9.2%, and mortality in 0.8% of patients. Total wound complications were significantly higher in the open OPM group (30%) (p = 0.009). Total surgery complications were significantly higher in the laparoscopic IPSDM group (15%) (p = 0.002). There was no significant difference between groups for medical complications (p = 0.540). Although no recurrence was observed in the open IPSDM group, no significant difference was observed between the groups (p = 0.099). There was no difference in mortality rates between the groups (p = 0.450). The overall complication rate was highest in the open OPM group (48.3%) and lowest in the open IPSDM group (27%) (p = 0.092). The operative time was found to be significantly shorter in open IPSDM (p < 0.001). The length of hospital stay was highest in the open OPM group and lowest in the open IPSDM group (p = 0.450). Conclusions Although hernia defect is greater in the open IPSDM compared to other methods, this method is more advantageous in terms of the complication rate associated with the surgical procedure, the overall complication rate, the duration of surgery, and the recurrence rate. Laparoscopic IPSDM is a more advantageous method in terms of the overall wound and medical complications.

Modern Principles of Medical Rehabilitation of Patients with Median Defects of the Abdominal Wall

Aim: To analyze rehabilitation and improvement of the quality of life of patients with median abdominal wall defects (MAWD) by increasing the efficiency of alloplasty by determining the general principles of planning and performing surgical interventions. Materials and methods: We carried out an analysis of the treatment results of 346 patients with MAWD, who underwent surgery in the 1st Poltava City Hospital for the period 2005-2019. There were 269 women (77.8%), men – 77 (22.2%). 282 (81.5%) patients underwent reconstructive surgeries, 59 (17.1%) – reconstructive and corrective alloplasty techniques, and 5 (1.4%) – corrective ones. Patients underwent surgery: onlay – in 3 patients (0.9%), sublay – in 289 (83.5%), sublay-inlay – in 38 (11.0%), inlay – in 4 (1.2%), Ramirez modification – in 10 (2.9%), open IPOM – in 2 (0.6%). Results: Local complications were in 25 (7.2%) cases: seroma in 12 (3.5%) patients, infiltrate in 5 (1.5%), necrosis of the edges in 4 (1.2%), hematoma – in 3 (0.9%), wound suppuration – in 1 (0.3%). In the remote period, 14 (4.1%) were registered: recurrence – 7 (2.0%); long-term deep seroma- 3 (0.9%); ligature fistulas with phlegmon – 2 (0.6%); abscess formation – 1 (0.3%), hernial sac infiltration – 1 (0.3%). Conclusions: The results of MAWD alloplasty depend on the correct solution of the planning problem and the choice of the most rational treatment tactics. Adequate abdominoplasty leads to an improvement in the quality of life of patients, medical and social rehabilitation.

EVOLUTION OF COMPONENT SEPARATION TECHNIQUE (REVIEW)

The problem of treatment of incisional ventral hernias is currently very relevant. The appearance of a hernial defect in the area of a previous operation is one of the most frequent long-term complications of any surgical treatment. Component separation techniques are the most modern and promising methods for the treatment of large ventral hernias. The review focuses on the main stages in the development of separation technique, as well as the results of treating patients with incisional ventral hernias using various options for posterior separation repair, which are currently frequently used. It has been established that posterior component separation is an effective and safe method of treatment, however, there is currently insufficient data on the long-term postoperative period and patients quality of life.

Abdominal Wall Skin Loss Defects Reconstruction Using Pedicled Anterolateral Thigh Flap

It was extremely difficult to deal with the complex full-thickness abdominal wall defect post serious trauma. The pedicled anterolateral thigh flap had been reported to be applied in reconstructing full-thickness abdominal wall defect in lower abdomen and groin. However, less cases in upper abdominal wall defect reconstructed by anterolateral thigh flap were reported due to some limitations. The aim of this study was to introduce our experiences in applying anterolateral thigh flap in upper abdominal wall defect reconstructing. In this study, seven patients with a large area of upper full-thickness defect in abdominal wall complicated with multiple organ damage were retrospectively identified due to acute trauma. Immediate organ-repair surgeries were performed. Meanwhile, the patients underwent complete debridement in the zone of abdominal wall defect, together with anti-infective treatment. Then, the appropriate timing was chosen to perform pedicled anterolateral thigh flap for reconstructing large area of full-thickness defect involving the upper abdomen. Postoperative follow-up data demonstrated that all the flaps survived, with no hernia complications or other discomforts. The outcome of the patients was also good. Thus, we conclude that pedicled anterolateral thigh flap was feasible to repair full-thickness defect in upper abdominal wall as long as well designed.

Primary and Recurrent Repair of Incisional Hernia Based on Biomechanical Considerations to Avoid Mesh-Related Complications

Aim: Mechanical principles successfully guide the construction of polymer material composites in engineering. Since the abdominal wall is a polymer composite augmented with a textile during incisional hernia repair we ask: can incisional hernia be repaired safely and durably based on biomechanical principles?

Material and Methods: Repair materials were assessed on a self-built bench test using pulse loads to elude influences on the reconstruction of the abdominal wall. Tissue elasticity was analyzed preoperatively as needed with computed tomography at rest and during Valsalva's maneuver. Preoperatively, the critical retention force of the reconstruction to pulse loads was calculated and a biomechanically durable repair was designed based on the needs of the individual patient. Intraoperatively, the design was adjusted as needed. Hernia meshes with high grip factors (Progrip^®, Dahlhausen^® Cicat) were used for the repairs. Mesh sizes, fixation elements and reconstructive details were oriented on the biomechanical design. All patients recieved single-shot antibiosis. Patients were discharged after full ambulation was achieved.

Results: A total of 163 patients (82 males and 81 females) were treated for incisional hernia in four hospitals by ten surgeons. Primary hernia was repaired in 119 patients. Recurrent hernia was operated on in 44 cases. Recurrent hernia was significantly larger (median 161 cm² vs. 78 cm²; u-test: p = 0.00714). Re-do surgery took significantly longer (median 229 min vs. 150 min; p < 0.00001) since recurrent disease required more often transversus abdominis release (70% vs. 47%). GRIP tended to be higher in recurrent repair (p = 0.01828). Complication rates (15%) and hospital stay were the same (6 vs. 6 days; p = 0.28462). After 1 year, no recurrence was detected in either group. Pain levels were equally low in both primary and recurrent hernia repairs (median NAS = 0 in both groups at rest and under load, p = 0.88866).

Conclusion: Incisional hernia can safely and durably be repaired based on biomechanical principles both in primary and recurrent disease. The GRIP concept provides a base for the application of biomechanical principles in incisional hernia repair.

Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality.

Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy.

Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.

[Surgical treatment of complex incisional hernia]

There is no generally accepted incisional hernia classification. To categorize incisional hernias, the European Hernia Society (EHS) proposed their classification based on the measurement of three parameters - location, dimension of hernia gate and recurrence. Unfortunately, this classification does not consider the «loss of the domain» of 20% or more, local complications including trophic ulcer or fistula of anterior abdominal wall. Moreover, implantation of mesh after previous hernia repair, obesity and other clinical factors are also not considered. Thus, surgeons have recently allocated patients with complex incisional hernia in a separate group. There is no clear definition of this term. There are no clinical guidelines on the management of patients with these hernias, and the choice of optimal surgical treatment remains individual. The authors present a patient with complex incisional hernia. Surgical strategy is described.

Simultaneous Complex Incisional Hernia Repair and Bariatric Surgery for Obese Patients: a Case Series of a Single-Center Early Experience

Purpose

Obesity is associated with recurrence of complex incisional hernia repair (CIHR). Bariatric procedure during CIHR can improve recurrence rates without increasing morbidity. This study aimed to describe our results after CIHR in patients with obesity, in which a simultaneous bariatric procedure was performed.

Materials and Methods

We performed a retrospective observational study including patients who underwent surgery between January 2014 and December 2018, with a complex incisional hernia (CIH) according to the Slater classification and body mass index (BMI) ≥35. CIHR was the main indication for surgery. We collected demographic data, comorbidities, CIH classification according to the European Hernia Society, type of bariatric procedure, postoperative morbidity using the Dindo-Clavien classification, and short-term results. Computed tomography (CT) is performed preoperatively.

Results

Ten patients were included in the study (7 women). The mean BMI was 43.63±4.91 kg/m². The size of the abdominal wall defect on CT was 8.86±3.93 cm. According to the European Hernia Society classification, all CIHs were W2 or higher. Prosthetic repair of the CIH was selected. Onlay, sublay, preperitoneal, and inlay mesh placement were performed twice each, as well as one modified component separation technique and one transversus abdominis release. Gastric leak after sleeve gastrectomy was the only major complication. Short-term outcomes included one recurrence, and % total weight loss was 24.04±8.03 after 1-year follow-up.

Conclusion

The association of bariatric procedures during CIHR seems to be feasible, safe, and could be an option for surgical treatment in selected patients.

Prophylactic Single-use Negative Pressure Dressing in Closed Surgical Wounds After Incisional Hernia Repair: A Randomized, Controlled Trial

OBJECTIVE

A randomized controlled trial (RCT) was undertaken to evaluate whether the prophylactic application of a specific single-use negative pressure (sNPWT) dressing on closed surgical incisions after incisional hernia (IH) repair decreases the risk of surgical site occurrences (SSOs) and the length of stay.

BACKGROUND

The sNPWT dressings have been associated to several advantages like cost savings and prevention of SSOs like seroma, hematoma, dehiscence, or wound infection (SSI) in closed surgical incisions. But this beneficious effect has not been previously studied in cases of close wounds after abdominal wall hernia repairs.

METHODS

An RCT was undertaken between May 2017 and January 2020 (ClinicalTrials.gov registration number NCT03576222). Participating patients, with IH type W2 or W3 according to European Hernia Society classification, were randomly assigned to receive intraoperatively either the sNPWT (PICO)(72 patients) or a conventional dressing at the end of the hernia repair (74 patients). The primary endpoint was the development of SSOs during the first 30 days after hernia repair. The secondary endpoint included length of hospital stay. Statistical analysis was performed using IBM SPSS Statistics Version 23.0.

RESULTS

At 30 days postoperatively, there was significatively higher incidence of SSOs in the control group compared to the treatment group (29.8% vs 16.6%, P < 0.042). There was no SSI in the treatment group and 6 cases in the control group (0% vs 8%, P < 0.002). No significant differences regarding seroma, hematoma, wound dehiscence, and length of stay were observed between the groups.

CONCLUSION

The use of prophylactic sNPWT PICO dressing for closed surgical incisions following IH repair reduces significatively the overall incidence of SSOs and the SSI at 30 days postoperatively.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Components separation technique of the abdominal wall: Which muscle release produces the greatest reduction in tension on the mideline?

BACKGROUND

The components separation technique (CS) is used for the reconstruction of complex abdominal wall defects. Release and undermining of the rectus abdominis muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline, reducing recurrence of ventral hernia, but causes major changes in the physiology of abdominal wall. The purpose of the study was to determine which muscle release and undermining produces the lowest tension on the midline.

METHODS

Twenty fresh cadavers were dissected and the anterior and posterior layers of the rectus sheath were isolated in the midline. The forces necessary to advance the layers of the rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after release and undermining of the right RAM and left EOM; and after release and undermining of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for the different muscles involved, layers of the rectus sheath, measurement points, and stages of separation.

RESULTS

Tension on the abdominal midline after the release and undermining of both the RAM and EOM was reduced by 56% (p <0.05), 42% after the release and undermining of the EOM alone (p <0.05), and 35% after release and undermining of the RAM alone (p <0.05).

CONCLUSION

Release and undermining of the EOM by CS led to lower tension on the abdominal midline compared to that associated with the release of the RAM alone.

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.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes

BACKGROUND

While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB).

METHODS

Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed.

RESULTS

A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m². Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05).

CONCLUSION

For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

What is the outcome of the open IPOM versus sublay technique in the treatment of larger incisional hernias?: A propensity score-matched comparison of 9091 patients from the Herniamed Registry

INTRODUCTION

In an Expert Consensus guided by systematic review, the panel agreed that for open elective incisional hernia repair, sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. This analysis of data from the Herniamed Registry aimed to compare the outcomes of open IPOM and sublay technique.

METHODS

Propensity score matching of 9091 patients with elective incisional hernia repair and with defect width ≥ 4 cm was performed. The following matching variables were selected: age, gender, risk factors, ASA score, preoperative pain, defect size, and defect localization.

RESULTS

For the 1977 patients with open IPOM repair and 7114 patients with sublay repair, n = 1938 (98%) pairs were formed. No differences were seen between the two groups with regard to the intraoperative, postoperative and general complications, complication-related reoperations and recurrences. But significant disadvantages were identified for the open IPOM repair in respect of pain on exertion (17.1% vs. 13.7%; p = 0.007), pain at rest (10.4% vs. 8.3%; p = 0.040) and chronic pain requiring treatment (8.8% vs. 5.8%; p < 0.001), in addition to rates of 3.8%, 1.1% and 1.1%, respectively, occurring in both matched patients. No relationship with tacker mesh fixation was identified. There are only very few reports in the literature with comparable findings.

CONCLUSION

Compared with sublay repair, open IPOM repair appears to pose a higher risk of chronic pain. This finding concords with the Expert Consensus recommending that incisional hernia should preferably be repaired using the sublay technique.

Giant desmoid tumour of abdominal wall: resection and reconstruction by posterior component separation

Management of large abdominal wall desmoid tumours is complicated due to the unpredictable behaviour of desmoids and the need for laborious reconstruction of the abdominal wall after wide local excision. A multidisciplinary team approach, including surgeons, oncologists and plastic surgeons, is necessary for proper management. This case highlights the diagnostic and surgical challenges related to the reconstruction of abdominal wall defect, after radical excision of a 30×30×25 cm desmoid tumour, originating from left rectus muscle. The defect was closed successfully by a perspicuous technique of posterior component separation. The awareness of this straightforward technique will allow the surgeons to do these radical procedures with confidence and without any consternation of complex reconstructive procedures.

Image-guided botulinum toxin injection in the lateral abdominal wall prior to abdominal wall reconstruction surgery: review of techniques and results

Ventral hernias represent the most common complication after abdominal surgery. Loss of domain and/or large ventral hernias in patients are especially challenging for surgeons to manage, but preoperative image-guided botulinum toxin injection has emerged as an effective adjunct to abdominal wall surgery. Loss of domain is caused by chronic muscle retraction of the lateral abdominal wall and leads to an irreducible protrusion of abdominal viscera into the hernia sac. Botulinum toxin can be used in the oblique muscles as a chemical component relaxation technique to aid abdominal wall reconstruction. Intramuscular botulinum toxin injection causes functional denervation by blocking neurotransmitter acetylcholine release resulting in flaccid paralysis and elongation of lateral abdominal wall muscles, increasing the rate of fascial closure during abdominal wall reconstruction, and decreasing recurrence rates. In total, 200-300 units of onabotulinumtoxinA (Botox®) or 500 units of abobotulinumtoxinA (Dypsort®) in a 2:1 dilution with normal saline is most commonly used. Botulinum toxin can be injected with ultrasonographic, EMG, or CT guidance. Injection should be performed at least 2 weeks prior to abdominal wall reconstruction, for maximal effect during surgery. At minimum, botulinum toxin should be injected into the external and internal oblique muscles at three separate sites bilaterally for a total of six injections. Although botulinum toxin use for abdominal wall reconstruction is currently not indicated by the Food and Drug Administration, it is safe with only minor complications reported in literature.

Ultrasound-Guided Chemical Component Separation with Botulinum Toxin A prior to Surgical Hernia Repair

US-guided chemical component separation (CCS) of the abdominal musculature using botulinum toxin A can facilitate the surgical repair of large or complex hernias. Eight patients (2 women and 6 men with median age of 54 years [range, 34-78 years]) underwent preoperative US-guided CCS with hydrodissection before planned surgical repair of large or complex ventral (n = 4), inguinal (n = 2), and flank (n = 2) hernias by 2 interventional radiologists. Technical success rate of US-guided CCS procedures was 100%, and all patients achieved surgical closure a mean 34.1 days (range, 14-48 days) after US-guided CCS.

The worst-case scenario: Bridging repair with a biologic mesh in high-risk patients with very large abdominal wall hernias-a prospective multicenter study

BACKGROUND

While modern techniques allow midline fascial closure for most abdominal hernias, a bridge repair with mesh may be the only alternative in very large defects. When the risk of infection is high, the use of prosthetic mesh is controversial. We aim to examine outcomes after bridge repair of very large abdominal hernias at high risk for postoperative infection with a second-generation biologic mesh.

METHODS

Prospective, multicenter, single-arm study of patients with very large abdominal hernias who received bridge repair with a neonatal bovine dermis mesh. Primary outcome was hernia recurrence, as identified on computed tomography 1 year after the operation. Secondary outcomes included mesh laxity, surgical site occurrences, and any other mesh-related complications. Independent risk factors of the outcomes were determined by univariate and multivariable analyses.

RESULTS

A total of 117 bridge repair patients were enrolled with a mean defect size of 442.5 ± 254.2 cm². The patients were predominantly obese (mean body mass index 36.5 ± 10.5) and with multiple comorbidities (Charlson comorbidity index 3 ± 2.5). Hernia recurrence was identified in 24 (20.5%) patients. An infected mesh at the index operation was an independent predictor of hernia recurrence, whereas obesity was an independent predictor of the pooled endpoint of recurrence and mesh laxity. Surgical site occurrences were recorded in 36.8% of the patients, and no independent risk factors were identified.

CONCLUSION

In patients with very large abdominal hernias and at high risk for postoperative infection, who cannot undergo midline fascial closure, a bridge repair with neonatal bovine dermis mesh offers an acceptable profile in terms of hernia recurrence and wound occurrences.

Can Electric Nose Breath Analysis Identify Abdominal Wall Hernia Recurrence and Aortic Aneurysms? A Proof-of-Concept Study

Introduction. This pilot study evaluates if an electronic nose (eNose) can distinguish patients at risk for recurrent hernia formation and aortic aneurysm patients from healthy controls based on volatile organic compound analysis in exhaled air. Both hernia recurrence and aortic aneurysm are linked to impaired collagen metabolism. If patients at risk for hernia recurrence and aortic aneurysms can be identified in a reliable, low-cost, noninvasive manner, it would greatly enhance preventive options such as prophylactic mesh placement after abdominal surgery. Methods. From February to July 2017, a 3-armed proof-of-concept study was conducted at 3 hospitals including 3 groups of patients (recurrent ventral hernia, aortic aneurysm, and healthy controls). Patients were measured once at the outpatient clinic using an eNose with 3 metal-oxide sensors. A total of 64 patients (hernia, n = 29; aneurysm, n = 35) and 37 controls were included. Data were analyzed by an automated neural network, a type of self-learning software to distinguish patients from controls. Results. Receiver operating curves showed that the automated neural network was able to differentiate between recurrent hernia patients and controls (area under the curve 0.74, sensitivity 0.79, and specificity 0.65) as well as between aortic aneurysm patients and healthy controls (area under the curve 0.84, sensitivity 0.83, and specificity of 0.81). Conclusion. This pilot study shows that the eNose can distinguish patients at risk for recurrent hernia and aortic aneurysm formation from healthy controls.

Poly-4-hydroxybutyrate (Phasix™) mesh onlay in complex abdominal wall repair

BACKGROUND

Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement.

METHODS

All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study.

RESULTS

105 patients (52 male, 53 female; mean age 59.2 years, range 22-84) met inclusion criteria. Mean BMI was 29.1 (range 16-48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9-63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma.

CONCLUSIONS

These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.

Is the sublay self-gripping mesh effective for incisional ventral hernia repair? Our experience and a systematic review of the literature

Sublay mesh repair seems to be the most effective method for treating incisional hernias (IHs). The aim of this study was to report our experience with retromuscular repair and self-gripping mesh for the treatment of midline IHs. In addition, we provided a systematic review of the literature regarding the use of this novel combination. All patients undergoing elective IH repair from June 2016 to November 2018 were included. The self-gripping mesh was placed in the sublay position. Demographic data, defect sizes, postoperative complications and follow-up durations were collected. A systematic review of the available literature was conducted in January 2020 using main databases. A total of 37 patients (20/17M/F) were included in this study, and the mean age and body mass index (BMI) were 58 years and 27 kg/m2, respectively. Minor complications occurred in six patients. Long-term follow-up demonstrated recurrence in three patients. Regarding the review, five publications were considered relevant. The highest complication rate was 28.6%, and the recurrence rate varied from 0 to 5.1%. This is the first review of the literature regarding sublay IH repair using a self-gripping mesh. The low rates of postoperative complications and recurrence in our experience and those reported by most of the reviewed articles demonstrate that this is a safe and effective method for repairing IHs.

Application of double circular suturing technique (DCST) in the repair of large abdominal wall defects after resection of abdominal wall tumor

Background

The aim of this study was to investigate the clinical effects of repairing large defects using the double circular suturing technique (DCST) after resection of abdominal wall tumor.

Methods

The clinical data of 62 patients (25 men, 37 women; average age 41.7±22.4 years) who underwent DCST between October 2010 and November 2018 for the repair of large abdominal wall defects with anti-adhesion underlay mesh after resection of abdominal wall tumor were retrospectively analyzed. The maximum diameter of abdominal wall defect after resection of abdominal wall tumor was 10.4±5.6 cm. The course of disease was 1–341 months, and the average was 32.4 months. Operative time, postoperative hospitalization time, perioperative complications, tumor recurrence in situ, incidence of postoperative chronic pain, and hernia were recorded.

Results

All 62 operations were completed successfully. The operative time was 73.2±31.4 minutes, and the mean postoperative hospitalization time was 9.6 days (range, 2–20 days). In total, 54 patients were followed up postoperatively for a median 6.7 years (range, 0.9–9.0 years). Partial splitting of incisions occurred in 2 patients, fat liquefaction of incisions occurred in 3 patients, and chronic pain occurred in 4 patients. No tumor in situ recurrence, hernia, or other complications were found in any cases in the follow-up. Tumor metastasis occurred in 9 patients with 6 of these patients dying of tumour progression.

Conclusions

With simple operations, short procedure time, few complications, low tumor recurrence rate, and low incidence of postoperative chronic pain, application of DCST in the repair of large abdominal wall defects is effective after resection of abdominal wall tumor.

Incisional hernia after liver transplantation: Risk factors, management strategies and long-term outcomes of a cohort study

INTRODUCTION

Incisional hernias (IH) develop in up to 40% of liver transplant (LT) recipients and can contribute to considerable morbidity.

MATERIALS AND METHODS

A single center retrospective review of a prospectively maintained LT database was conducted to identify all patients diagnosed with IH after LT during a 13-year study period (2003-2015). Analyzed data included patient demographics, LT details, incidence and timing of IH, risk factors, management strategies and long-term outcomes.

RESULTS

During the 13-year study period, IH was diagnosed in 16.7% (163/976) of LT recipients after a median of 19.6 months (range 6.7-49.5 months) from transplant surgery. Identified risk factors for developing IH included male gender (p < 0.001) while acute cellular rejection (ACR) was found to be negatively associated with the risk of developing IH (p = 0.014). Acute incarceration/strangulation was seen in 4 patients with IH while the remaining (n = 159) presented with non-emergent symptoms. Surgical repair was undertaken in 70/163 (43%) IH patients after medical optimization when possible (open repair 83%, mesh use 90%). IH recurrence rate was 14.3% (10/70) with comparable rates in no-mesh and with-mesh repairs (42.9% vs. 11.3%; p = 0.057) and open (15.8%) and laparoscopic (9.1%) approaches (p = 0.68).

CONCLUSION

IH is a late complication following LT and male gender is a consistent predictive marker. Acute presentation is infrequent and elective repair can be planned in most patients allowing for risk factor optimization to ensure promising long-term outcomes.

Drain tube use in incisional hernia repair: a national survey

PURPOSE

There is debate regarding the use of drain tubes in incisional hernia repair. This has become topical in Australia, with a court judge suggesting that drain tubes are mandatory. There continues to be a lack of evidence to support generalised decision-making regarding the use of drain tubes.

METHODS

The general surgeon membership of General Surgeons Australia (GSA) were surveyed regarding incisional hernia repair, their use of drains, and the decision-making behind their use.

RESULTS

A total of 196 surgeons' survey responses were analysed. Most surgeons perform less than 20 incisional hernia repairs per year (78%), prefer an open approach (78%), and preferably perform a pre-peritoneal (sub-lay) repair (53%). There was a variety of approaches to leaving a drain, with the most common answer being "sometimes" (31.28%) and an equal number of surgeons claiming to always or never leaving a drain (11.79% each). There was also no consensus in the duration the drain should stay in, with most surgeons averaging less than 5 days. Interestingly, there was a range of views on the effects of drain tubes, with some surgeons believing drains decreased infections and more believing they increased infections. Most surgeons felt seromas were decreased, but there was increased post-operative pain. The majority of surgeons agreed there was no evidence to support their beliefs.

CONCLUSION

Placement of drain tubes is not universally practiced by the general surgeons who participated in the survey. The lack of evidence is reflected by a varied approach to incisional hernia repair and the use of drain tubes.

Peritoneal flap hernioplasty for reconstruction of transverse incisional hernias

BACKGROUND

Repair of transverse incisional hernias is a surgical challenge with current methods of abdominal wall reconstruction. The peritoneal flap hernioplasty addresses this problem using flaps of hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. The operative technique and long-term results of 80 consecutive cases with transverse incisional hernias undergoing repair with this method are reported.

METHODS

Patients undergoing elective peritoneal flap hernioplasty repair for transverse incisional hernias from Jan. 1, 2010 to Dec. 31, 2014 were identified from the Lothian Surgical Audit system, a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in May 2019 from hospital records and telephone interview.

RESULTS

80 patients, (n = 53 male, 66%) were identified. Mean follow-up was 83 months (range 55-114 months) and mean postoperative stay was 6.4 days (range 1-23 days). Eleven repairs (14%) were for recurrent hernia. Mean mesh size applied (Optilene Elastic, 48 g/m², BBraun) was 747 cm² (ranged 150-1500 cm²). Redundant skin excision was performed in 54% of cases. Altogether, seven patients (8.8%) presented with postoperative complications: five superficial wound infections (6.3%), one symptomatic seroma (1.3%) and one recurrence (1.3%) within the follow-up period.

CONCLUSION

The peritoneal flap hernioplasty is associated with few complications and a very low recurrence rate. We propose this technique as the method of choice for reconstruction of transverse abdominal incisional hernias when primary fascial apposition is not possible.

Comparative study of four different types of intraperitoneal mesh prostheses in rats

Purpose:

To compare four types of mesh regarding visceral adhesions, inflammatory response and incorporation.

Methods:

Sixty Wistar rats were divided into four groups, with different meshes implanted intraperitoneally: polytetrafluoroethylene (ePTFE group); polypropylene with polydioxanone and oxidized cellulose (PCD); polypropylene (PM) and polypropylene with silicone (PMS). The variables analyzed were: area covered by adhesions, incorporation of the mesh and inflammatory reaction (evaluated histologically and by COX2 immunochemistry).

Results:

The PMS group had the lowest adhesion area (63.1%) and grade 1 adhesions. The ePTFE and PM groups presented almost the total area of their surface covered by adherences (99.8% and 97.7% respectively) The group ePTFE had the highest percentage of area without incorporation (42%; p <0.001) with no difference between the other meshes. The PMS group had the best incorporation rate. And the histological analysis revealed that the inflammation scores were significantly different.

Conclusions:

The PM mesh had higher density of adherences, larger area of adherences, adherences to organs and percentage of incorporation. ePTFE had the higher area of adherences and lower incorporation. The PMS mesh performed best in the inflammation score, had a higher incorporation and lower area of adherences, and it was considered the best type of mesh.

Comparative study of peritoneal adhesions after intraperitoneal implantation in rats of meshes of polypropylene versus polypropylene/polyglecaprone versus polyester/porcine collagen

PURPOSE

To Compare the extent and intensity of adhesions formed between the intra-abdominal organs and the intraperitoneal implants of polypropylene mesh versus polypropylene/polyglecaprone versus polyester/porcine collagen used for correction of abdominal wall defect in rats.

METHODS

After the defect in the abdominal wall, thirty Wistar rats were placed in three groups (ten animals each) for intraperitoneal mesh implant: polypropylene group, polypropylene/polyglecaprone group, and polyester/porcine collagen group. The macroscopic evaluation of the extent and intensity of adhesions was performed 21 days after the implant.

RESULTS

The polypropylene group had a higher statistically significant impairment due to visceral adhesions (p value = 0.002) and a higher degree of intense adherence in relation to polypropylene/polyglecaprone and polyester/porcine collagen groups (p value<0.001). The polyester/porcine collagen group showed more intense adhesions than the polypropylene/polyglecaprone group (p value=0.035).

CONCLUSIONS

The intraperitoneal implantation of polypropylene meshes to correct defects of the abdominal wall caused the appearance of extensive and firm adhesions to intra-abdominal structures. The use of polypropylene/polyglecaprone or polyester/porcine collagen tissue-separating meshes reduces the number and degree of adhesions formed.

Modified Peritoneal Flap Hernioplasty Versus Retromuscular Technique for Incisional Hernia Repair: a Retrospective Cohort Study

BACKGROUND AND AIMS

We present an open retromuscular mesh technique for incisional hernia repair, the modified peritoneal flap hernioplasty, where the fascia is sutured to the mesh and the hernia sac utilized for anterior mesh coverage. The aim was to describe the modified peritoneal flap hernioplasty technique and to compare it to a retromuscular repair, without component separation, regarding short-term complications, patient satisfaction, abdominal wall complaints, and recurrent incisional hernia.

MATERIALS AND METHODS

Consecutive patients operated electively with modified peritoneal flap hernioplasty technique (December 2012-December 2015) or retromuscular technique (Jan 2011-Oct 2014) were included in a retrospective single-center cohort study. Outcomes were evaluated from the Swedish Ventral Hernia Registry, by chart review, physical examination, and an abdominal wall complaints questionnaire.

RESULTS

The modified peritoneal flap hernioplasty group (n = 78) had larger hernias (mean width 10.4 vs 8.5 cm, p = 0.005), more advanced Centers for Disease Control classification (p = 0.009), and more simultaneous gastrointestinal-tract surgery (23.1% vs 11.5%, p = 0.041) than the retromuscular group (n = 96). No difference in short-term complications was seen. Incisional hernia recurrence was lower in the modified peritoneal flap hernioplasty group (1.4% vs 10.3%, p = 0.023), and patients were more satisfied (93.8% vs 81.7%, p = 0.032). Follow-up time was shorter in the modified peritoneal flap hernioplasty group (614 vs 1171 days, p < 0.001).

CONCLUSION

This retrospective study showed similar rates of short-term complications, despite more complex hernias in the modified peritoneal flap hernioplasty group. Furthermore, a lower incisional hernia recurrence rate for the modified peritoneal flap hernioplasty technique compared with the retromuscular technique used in our department was found. If this holds true with equally long follow-up remains to be proven.

Is Onlay Polypropylene Mesh Repair an Available Option for Incisional Hernia Repair? A Retrospective Cohort Study

Lately, incisional hernia repair (IHR) with onlay polypropylene mesh has been replaced by other surgical procedures. The aim of this study was to compare the complication and recurrence rate after onlay mesh repair and other surgical procedures for IHR. A retrospective cohort study of patients who underwent IHR in a single center was conducted. The data were obtained from electronic medical records. Patients who had been lost during follow-up were contacted for a visit in the clinic. Univariate and multivariate analysis was performed with Stata 13.0 to analyze the factors associated with postoperative complications and hernia recurrence. Between June 2004 and December 2015, 1078 patients underwent IHR in a single center. Onlay mesh repair was performed in 125 patients (11.6%). Other surgical procedures included Rives procedure (29.3%), sublay mesh repair (38.6%), intrabdominal mesh repair (17.1%), and primary closure (3.4%). After a mean follow-up of 2.8 years, 73 (7%) patients developed a recurrence. A higher percentage of complications were seen after onlay mesh repair than after other surgical procedures (22.4% vs 13.1%, P = 0.005). Nevertheless, recurrence was less frequent after onlay mesh repair (4.2% vs 7.1%, P = 0.241). Logistic regression discarded an association between onlay mesh repair and hernia recurrence or postoperative complications. Incisional hernia repair with onlay polypropylene mesh repair was not associated with a higher incidence of postoperative complications or recurrence rate. So, this procedure should not be discarded in selected patients presenting with incisional hernia.

Risk Factors for Surgical Complications in Ventral Hernia Repair

BACKGROUND

The aim of this study was to identify risk factors for an adverse event, i.e. early surgical complication, need for ICU care and readmission, following ventral hernia repair. Our hypothesis was that there is an association between an increased complication rate following ventral hernia repair and specific factors, including hernia size, BMI > 35, concomitant bowel surgery, ASA-class, age, gender and method of hernia repair.

METHODS

Data from a hernia database with prospectively entered data on 408 patients operated for ventral hernia between 2007 and 2014 at two Swedish university hospitals were analysed. A 3-month follow-up of complications, need for intensive care and readmission, was performed by reviewing the medical records.

RESULTS

Eighty-one of 408 patients (20%) had a registered complication. Fifty-eight (14%) of these were classed as Clavien I-IIIa, and in 19 cases a Clavien IIIb-IV complication was reported. Large hernia size was associated with increased risk for early complication. A Kendall Tau test analysis revealed a proportional relationship between hernia size and modified Clavien outcome class (p < 0.001). Morbid obesity, ASA-class, method, hernia recurrence, age and concomitant bowel surgery were not statistically significant predictors of adverse events.

CONCLUSIONS

Assessment of hernia aperture size is of great importance in the preoperative evaluation of ventral hernia patients to consider risk for post-operative complications. These results suggest a careful attitude when applying watchful waiting concepts and when postponing hernia surgery to achieve weight loss. A delaying attitude may result in increased risk of complications caused by increasing hernia size.