The increased cost of ventral hernia recurrence: a cost analysis

Ventral hernia repair using bioresorbable poly-4-hydroxybutyrate mesh in clean and contaminated surgical fields: a systematic review and meta-analysis

PURPOSE

Use of biologic or synthetic mesh in hernia repair shifts is based on evolving evidence. Poly-4-hydroxybutyrate (P4HB) biosynthetic mesh is a potential alternative to biologic and synthetic mesh in ventral hernia repair (VHR). This meta-analysis assesses the efficacy of P4HB mesh in clean and contaminated surgical settings.

METHODS

Two authors searched literature on PubMed, reviewing titles and abstracts of all articles to determine inclusion eligibility. Post-operative data were compared via transformation method to convert the proportion of patients with the outcome of interest into a suitable quantity for random-effects synthesis using STATA software.

RESULTS

Initial search yielded 287 citations. Six studies were included and categorized on whether hernia repairs were conducted in clean (CDC class I) or contaminated cases (CDC class II-IV). The pooled proportion of surgical site infection (SSI), surgical site occurrence (SSO), hernia recurrence, total surgical complications, and reoperation were calculated in 391 clean and 81 contaminated cases. For clean vs. contaminated cases, the following pooled proportions were noted: SSI (2% (CI 0-7%) vs 9% (CI 0-025) (p = 0.03), SSO: 14% (CI 5-25%) vs 35% (CI 22-50%) (p = 0.006), hernia recurrence (8% (CI 1-19%) vs 4% (CI 0-12%) (p = 0.769); surgical complications (17% (CI 6-32%) vs 50% (CI 27-72%) (p = 0.009). Reoperation data were available in 298 clean cases across four studies: 5% (CI 0-15%).

CONCLUSIONS

P4HB biosynthetic mesh may be more effective than previously thought, particularly in clean wounds. P4HB may also be superior to biologic mesh when compared to clinical trial data. Further research is necessary for more direct comparison.

Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields

INTRODUCTION

The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh.

MATERIALS METHODS

Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed.

RESULTS

Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m2, and a defect size of 356.9 ± 227.7 cm2. Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications.

CONCLUSIONS

Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.

Incisional hernias post cytoreductive surgery/peritonectomy and hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis

PURPOSE

Cytoreductive surgery (CRS) is often combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of peritoneal tumour deposits. Considering CRS, the evidence relating the large incisions, local chemotherapy and abdominal wall trauma to incisional hernias (IH) has not been synthesized. This systematic review and meta-analysis was conducted to examine the proportion of IH present in patients post CRS and the effect HIPEC had on these rates.

METHODS

PubMed, EMBASE, and Cochrane Central Registry of Trials were searched up to June 2023 to examine studies relating IH and CRS plus or minus HIPEC. The most up to date PRISMA guidelines were followed. Pertinent clinical information was synthesized in tabular form. A meta-analysis reporting the pooled proportions of IH post CRS plus or minus HIPEC, the odds of IH in HIPEC versus non-HIPEC CRS and the difference in follow-up time between groups was conducted.

RESULTS

Nine studies comprising 1416 patients were included. The pooled proportion of IH post CRS was 12% (95% confidence interval (CI) 8-16%) in HIPEC and 7% (95% CI 4-10%) in non-HIPEC patients and 11% (95% CI 7-14%) overall. Previously reported rates of IH in midline laparotomy range from 10 to 30%. The odds of IH in the HIPEC was 1.9 times higher compared to non-HIPEC cohorts however this was not statistically significant (odds ratio (OR) 1.9, 95% 0.7-5.2; p = 0.21). There was no significant difference in average follow-up times between HIPEC and non-HIPEC cohorts.

CONCLUSIONS

IH post CRS plus or minus HIPEC were in the expected range for midline laparotomies. IH in patients receiving HIPEC may occur at a greater proportion than in non-HIPEC patients, however, there were too few studies in our meta-analysis to determine this with statistical significance.

Minimally invasive approach to incisional hernia in elective and emergency surgery: a SICE (Italian Society of Endoscopic Surgery and new technologies) and ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) online survey

Minimally invasive abdominal wall surgery is growing worldwide, with a constant and fast improvement of surgical techniques and surgeons' confidence in treating both primary and incisional hernias (IH). The Italian Society of Endoscopic Surgery and new technologies (SICE) and the ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) worked together to investigate state of the art in IH treatment in elective and emergency settings in Italy. An online open survey was designed, and Italian surgeons interested in abdominal wall surgery were invited to fill out a 20-point questionnaire on IH surgical procedures performed in their departments. Surgeons were asked to express their points of view on specific questions about technical and clinical variables in IH treatment. Preferred approach in elective IH surgery was minimally invasive (59.7%). Open surgery was the preferred approach in 40.3% of the responses. In emergency settings, open surgery was the preferred approach (65.4%); however, 34.5% of the involved surgeons declare to prefer the laparoscopic/endoscopic approach. Most respondents opted for conversion to open surgery in case of relevant surgical field contamination, with a non-mesh repair of abdominal wall defects. Among those that used the laparoscopic approach in the emergent setting, the majority (74%) used the size of the defect of 5 cm as a decisional cut-off. The spread of minimally invasive approaches to IH repair in emergency surgery in Italy is gaining relevance. Code-sharing through scientific societies can improve clinical practice in different departments and promote a tailored approach to IH surgery.

Ventral hernia repair: an increasing burden affecting abdominal core health

PURPOSE

To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index.

RESULTS

On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019.

CONCLUSION

Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.

Ventral hernia repair: an increasing burden affecting abdominal core health

PURPOSE

To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index.

RESULTS

On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019.

CONCLUSION

Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.

Outcomes of redo-transversus abdominis release for abdominal wall reconstruction

BACKGROUND

Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR.

STUDY DESIGN

Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life.

RESULTS

Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m². Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median  - 9.5).

CONCLUSION

Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures.

Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy

Importance

The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden.

Objective

To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings.

Design, Setting, and Participants

This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020.

Main Outcomes and Measures

The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH.

Results

Of 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions.

Conclusions and Relevance

Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.

Recurrent incisional hernia repairs at a tertiary hernia center: Are outcomes really inferior to initial repairs?

BACKGROUND

Recurrent ventral hernia repairs are reported to have higher recurrence and complication rates than initial ventral hernia repairs. This is the largest analysis of outcomes for initial versus recurrent open ventral hernia repairs reported in the literature.

METHODS

A prospective, institutional database at a tertiary hernia center was queried for patients undergoing open ventral hernia repairs with complete fascial closure and synthetic mesh placement.

RESULTS

A total of 1,694 open ventral hernia repairs patients were identified, including 896 (52.9%) initial ventral hernia repairs and 798 (47.1%)recurrent ventral hernia repairs. Recurrent ventral hernia repair patients were more complex: older (P = .003), higher body mass index (P < .001), higher American Society of Anesthesiologists class (P < .001), incidence of diabetics (P = .003), comorbidities (P < .001), and larger hernia defects (133.3 ± 171.9 vs 220.2 ± 210.0; P < .001). Recurrent ventral hernia repairs also had longer operative times (161.6 ± 82.4 vs 188.2 ± 68.9 minutes; P < .001), increased use of preoperative botulinum toxin A injection (4.3% vs 10.1%; P = .01), components separation (19.2% vs 39.5%; P < .001), and panniculectomy (20.3% vs 35.8%; P < .001). The overall hernia recurrence rate was 4.4% at a mean follow-up of 36.6 ± 45.5 months. Between the initial ventral hernia repairs and recurrent ventral hernia repairs, the hernia recurrence rates were equivalent (4.2% vs 4.7%, P = .63). Rates of wound infection, seromas, hematomas, mesh infections, and wound related reoperations (P > .05) were nonsignificant.

CONCLUSION

At a tertiary hernia center, despite higher-risk patients, larger hernia defects, and increased components separation in recurrent ventral hernia repairs, early recurrence rates, wound complications, and reoperations are similar to initial ventral hernia repairs.

Hybrid approach to ventral wall hernia repair: a single-institution cohort study

Background

Ventral hernias pose a substantial challenge for surgeons. Even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardised method that has been widely accepted as standard of practice. Hybrid ventral hernia repair (HVR) is an alternative surgical approach, which has not been adopted widely to date. It combines laparoscopic mesh insertion with closure of the hernia defect. The aim of this retrospective cohort study is to evaluate short- and long-term outcomes in patients undergoing HVR.

Methods

Between October 2012 and June 2016, 56 HVRs were performed at St Mary’s Hospital, Imperial College London. The medical records of these patients were reviewed retrospectively for demographics, comorbidities, previous surgeries, operative technique, complications and recurrences over a 3-year follow-up.

Results

HVRs were performed by four surgeons. Mean age was 48 years with a mean body mass index (BMI) of 32.8 kg/m2. 71.4% had incisional hernias and 28.6% had primary hernias. The number of hernia defects ranged from 1 to 4, with average defect size 42.9 cm2 (range 8–200 cm2). Adhesiolysis was performed in 66.1% of patients. Recurrence occurred in 2 patients (3.6%), 16.1% of patients developed postoperative seroma, 0.3% had respiratory complications, 0.3% had paralytic ileus and 0.2% had urinary retention. Only 2 patients required epidural postoperatively, both had a defect size of 150.0 cm2. There were no reoperations within 90 days. Mean length of hospital stay was 2 days (1–10 days). Over the follow-up period, 2 patients (3.6%) developed chronic pain.

Conclusion

The hybrid technique is safe and feasible, and has important benefits including low rates of seroma formation, chronic pain and hernia recurrence. Future investigations may include randomised controlled trials to evaluate the benefits of VHR, with careful assessment of patient-reported outcome measures including quality of life and postoperative pain.

[Minimally invasive ventral hernia repair: apply or save?]

Treatment of patients with ventral hernias remains one of the most pressing problems of abdominal surgery. Surgeons are trying to find a «gold standard» for the treatment of this pathology. Great hopes are placed on minimally invasive techniques, however, due to their high cost, they do not yet find mass distribution in everyday practice. In our opinion, this is short-sighted. We tried to analyze the feasibility of using minimally invasive techniques in the treatment of patients with ventral hernias of various locations, from the position of clinical and economic efficiency.

Dual Tack Mesh Fixation System on a Cadaveric Porcine Model-Creation of a Mesh Fixation System for Hernia Treatment and Prevention

BACKGROUND

Onlay mesh repair (OMR) has proven to be a widely used, simple, and effective technique for treatment and prevention of hernia occurrence. Despite established benefits, there is still a lack of widespread adoption. In this study, we present the Dual Tacker Device (DTD), an enabling technology that directly addresses the limitations to the adoption of OMR, saving surgical time and effort and making OMR more reproducible across a wide range of patients.

METHODS

The DTD mesh fixation system is a semiautomated, hand-held, disposable, multipoint onlay mechanical mesh fixation system that is able to rapidly and uniformly tension and fixate mesh for both hernia treatment and prevention. A cadaveric porcine model was used as a pilot test conducted during a 2 day session to assess the usability of the device and to show that the DTD provided equivalent or superior biomechanical support compared with the standard of care (hand-sewn, OptiFix).

RESULTS

Our study included 37 cadaveric porcine incisional closure abdominal wall models. These were divided into four groups: DTD-mediated OMR (n = 14), hand-sewn OMR (n = 7), OptiFix OMR (n = 9), and suture-only repair (no mesh) (n = 7). Eight surgical residents performed device-mediated and hand-sewn OMR. Average time to completion was fastest in the DTD cohort (45.6s) with a statistically significant difference compared with the hand-sewn cohort (343.1s, P < 0.01). No difference in tensile strength was noted between DTD (195.32N), hand-sewn (200.48N), and OptiFix (163.23N). Discreet hand movements were smallest in the DTD (29N) and significant (P < 0.01) when compared with hand-sewn (202N) and OptiFix (35N).

CONCLUSIONS

The use of the DTD is not only feasible, but demonstrated improvement in time to completion and economy of movement over current standard of care. While more testing is needed and planned, compared with conventional approaches, the DTD represents a robust proof of principle with promising implications for clinical feasibility and adoptability.

Analysis of 4,015 recurrent incisional hernia repairs from the Herniamed registry: risk factors and outcomes

INTRODUCTION

The proportion of recurrences in the total collective of all incisional hernias has been reported to be around 25%. In the European Hernia Society (EHS) classification, recurrent incisional hernias are assigned to a unique prognostic group and considered as complex abdominal wall hernias. Surgical repairs are characterized by dense adhesions, flawed anatomical planes caused by previous dissection or mesh use, and device-related complications. To date, only relatively small case series have been published focusing on outcomes following recurrent incisional hernia repair. This cohort study now analyzes the outcome of recurrent incisional hernia repair assessing potential risk factors based on data from the Herniamed registry. Special attention is paid to the technique used during the primary incisional hernia repair, since laparoscopic IPOM was recently deemed to cause more complications during subsequent repairs.

METHODS

In the multicenter Internet-based Herniamed registry, patients with recurrent incisional hernia repair between September 2009 and January 2018 were enrolled. In a confirmatory multivariable analysis, factors potentially associated with the outcome parameters (intraoperative, postoperative and general complications, complication-related reoperations, re-recurrences, pain at rest and on exertion, and chronic pain requiring treatment at one-year follow-up) were evaluated.

RESULTS

In total, 4015 patients from 712 participating hospitals were included. Postoperative complications and complication-related reoperations were significantly associated with larger recurrent hernia defect size, open recurrent incisional hernia repair and the use of larger meshes. General complications were more frequent in female sex patients and when larger meshes were used. Higher re-recurrence rate was observed with lateral defect localization, present risk factors, and time interval ≤ 1 year between primary and recurrent incisional hernia repair. Pain rates at 1-year follow-up were unfavorably related with pre-existing preoperative pain, female sex, lateral defect localization, larger mesh, presence of risk factors, and postoperative complications. As regards the primary incisional hernia repair technique, laparoscopic IPOM was found to show no effect versus open mesh techniques on the subsequent recurrence repair, despite a trend toward higher rates of complication-related reoperations.

CONCLUSION

The outcomes of recurrent incisional hernia repair were significantly associated with potential influencing factors, which are very similar to the factors seen in primary incisional hernia repair. The impact of the primary incisional hernia repair technique, namely laparoscopic IPOM versus open mesh techniques, on the outcome of recurrent incisional hernia repair seems less pronounced than anticipated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

When the Mesh Goes Away: An Analysis of Poly-4-Hydroxybutyrate Mesh for Complex Hernia Repair

Mesh reinforcement is a cornerstone of modern ventral hernia repair (VHR); yet, complications with synthetic mesh and cost of biologic have created a need for alternative options. Biosynthetic mesh is a resorbable scaffold that theoretically leverages the benefits and minimizes deficiencies of existing mesh types. This study evaluates 2-year outcomes following poly-4-hydroxybutyrate (P4HB) mesh reinforcement for complex VHR.

Methods

A retrospective review of all consecutive VHR with P4HB (n = 70) was conducted from 2015 to 2018 by a single surgeon. Clinical outcomes, quality of life (QoL; and cost were assessed.

Results

Seventy patients were included with an average age and body mass index of 58.6 years and 33 kg/m², respectively. High-risk comorbidities included hypertension (59%), and smoking history (50%). Cases were primarily modified Ventral Hernia Working Group class 2 (50%), or 3 (36%), with average defect size of 323 cm² (25-972 cm²). P4HB was placed in the retromuscular (80%) or onlay (20%) plane. Mean follow-up was 24 months (12.2-41 months). Hernia recurrence rate was 5.7% (n = 4) and occurred an average of 285 days (209-368 days) post-repair. Of the 21 surgical site occurrences (SSO), 5 (7%) required surgical intervention. A significant improvement in overall QoL (P = 0.001) was noted following repair. Defect size and SSOPI were independently associated with increased direct cost.

Conclusions

P4HB mesh for complex VHR is associated with favorable 2-year clinical outcomes, acceptable hernia recurrence rate, and a significant improvement in QoL. This study supports the use of biosynthetic mesh as an effective biomaterial for complex VHR.

Enhanced value with implementation of an ERAS protocol for ventral hernia repair

BACKGROUND

Open ventral hernia repair (VHR) is associated with postoperative complications and hospital readmissions. A comprehensive Enhanced Recovery after Surgery (ERAS) protocol for VHR contributes to improved clinical outcomes including the rapid return of bowel function and reduced infections. The purpose of this study was to compare hospital costs for patients cared for prior to ERAS implementation with patients cared for with an ERAS protocol.

METHODS

With IRB approval, clinical characteristics and postoperative outcomes data were obtained via retrospective review of consecutive VHR patients 2 years prior to and 14 months post ERAS implementation. Hospital cost data were obtained from the cost accounting system inclusive of index hospitalization. Clinical data and hospital costs were compared between groups.

RESULTS

Data for 178 patients (127 pre-ERAS, 51 post-ERAS) were analyzed. Preoperative and operative characteristics including gender, ASA class, comorbidities, and BMI were similar between groups. ERAS patients had faster return of bowel function (p = 0.001) and decreased incidence of superficial surgical site infection (p = 0.003). Hospital length of stay did not vary significantly pre and post ERAS implementation. Inpatient pharmacy costs were increased in ERAS group ($2673 vs. $1176 p < 0.001), but total hospital costs (14,692 vs. 15,151, p = 0.538) were similar between groups.

CONCLUSIONS

Standardization of hernia care via ERAS protocol improves clinical outcomes without impacting total costs.

Ascending the Learning Curve of Robotic Abdominal Wall Reconstruction

Background:

Robotic complex abdominal wall reconstruction (r-AWR) using transversus abdominis release (TAR) is associated with decreased wound complications, morbidity, and length of stay compared with open repair. This report describes a single-institution experience of r-AWR.

Methods:

A retrospective chart review was performed on patients who underwent r-AWR by a single surgeon (D.H.) from August 2015 through October 2018.

Results:

Fifty-five patients underwent r-AWR (16 males [29%] and 39 females [71%]) with a mean age of 60.2 (range 33 to 87) years and a mean body mass index of 34.6 (range 23 to 54) kg/m². Forty-one patients presented with an initial ventral hernia (74.5%) and 14 with a recurrent hernia (25.5%). Five patients had a grade 1 hernia (9.1%), 46 had a grade 2 hernia (83.6%), and 4 had a grade 3 hernia (7.3%) according to the Ventral Hernia Working Group system. Thirty-four (62%) patients underwent TAR, 21 (38%) patients underwent bilateral retrorectus release, and 10 (18.2%) patients underwent concomitant inguinal hernia repair. Mean operative time with TAR was 294 (range 106 to 472) minutes and 183 (range 126 to 254) minutes without TAR. Mean length of stay was 1.5 (range 0 to 10) days. Mean follow-up was 10.7 (range 1 to 52) weeks with no hernia recurrences. Seromas occurred in 6 (10.9%) patients, with 2 (3.6%) requiring drainage. Two (3.6%) 30-day readmissions occurred with no conversions to open or 30-day mortalities.

Conclusions:

r-AWR with and without TAR is a safe and feasible procedure associated with a short LOS, low complication rate, and low recurrence even within the surgeon's learning curve experience.

Retrorectus repair of incisional ventral hernia with urinary bladder matrix reinforcement in a long-term porcine model

Aim: Not all biologically derived materials elicit the same host response when used for reinforcement of ventral hernia repairs. This study aimed to evaluate the remodeling characteristics of the abdominal wall following reinforcement with urinary bladder matrix (UBM) in a large animal preclinical model of ventral hernia repair. Materials & methods: Midline defects in 36 Yucatan minipigs were reinforced with UBM-derived surgical devices using a classic Rives–Stoppa–Wantz approach, and compared with primary repair controls. After 3 or 8 months, the abdominal wall was explanted for histological and mechanical analysis. Results & conclusion: All UBM-derived surgical devices were completely resorbed within 8 months and facilitated deposition of vascularized, biomechanically functional connective tissue in the retrorectus plane, with no evidence of hernia formation.