Risk-adjusted procedure tailoring leads to uniformly low complication rates in ventral and incisional hernia repair: a propensity score analysis and internal validation of classification criteria

Do antiplatelets and anticoagulants have an impact on the clinical outcomes of robotic ventral hernia repair?

BACKGROUND

We sought to study the impact of antithrombotics(antiplatelets and anticoagulants) on robotic ventral hernia repair(RVHR).

METHODS

RVHR cases were divided into antithrombotic (AT) (-) and AT (+) groups. After comparing both groups, a logistic regression analysis was performed.

RESULTS

611 patients had no AT-medication. The AT(+) group had 219 patients of which 153 were only on antiplatelets, 52 only on anticoagulants, and 14(6.4%) patients on both antithrombotics. Mean age, American Society of Anesthesiology scores, and comorbidities were significantly higher in the AT(+) group. Intraoperative blood loss was greater in the AT(+) group. Postoperatively, the AT(+) group had greater rates of Clavien-Dindo grade-II and IV-a complications(p=0.001, and p=0.013, respectively), and postoperative hematomas(p=0.013). Mean follow-up was greater than 40 months. Age[Odds Ratio(OR): 1.034] and anticoagulants(OR: 3.121) were associated with increased bleeding-related events.

CONCLUSION

There were no associations between maintained antiplatelet therapy and postoperative bleeding-related events in RVHR whereas age and anticoagulants had the highest association.

Robotic hernia repair III. English version : Robotic incisional hernia repair with transversus abdominis release (r‑TAR). Video report and results of a cohort study

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aCS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pCS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pCS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

Robotic hernia repair II. English version : Robotic primary ventral and incisional hernia repair (rv‑TAPP and r‑Rives or r‑TARUP). Video report and results of a series of 118 patients

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r‑ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r‑TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

[Robotic hernia repair : Part III: Robotic incisional hernia repair with transversus abdominis release (r-TAR). Video report and results of a cohort study]

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aKS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pKS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pKS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

Excess Body Weight and Abdominal Hernia

Background

Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI.

Summary

This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young.

Key Messages

Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

[Robotic hernia repair : Part II: Robotic primary ventral and incisional hernia repair (rv-TAPP and r-Rives or r-TARUP). Video report and results of a series of 118 patients]

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r‑ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r‑TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

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.

Incisional hernia repair in a high-fidelity silicone model for open retro-muscular mesh implantation with preparation of the fatty triangle: validation and educational impact study

BACKGROUND

Incisional hernia repair requires detailed anatomic knowledge. Regarding median subxiphoidal hernias, the proper preparation of the fatty triangle is challenging. To foster proficiency-based training, a cost-efficient model for open median retromuscular mesh repair resembling the human body was developed, including the main anatomical structures related to the procedure. The aim is to create and validate a high-fidelity model on open retromuscular mesh repair suitable for "training before doing".

MATERIALS AND METHODS

Different types of fabrics for imitation of connective tissue and 2-component silicones were used to construct the incisional hernia model. Sample size for validation of the model was determined by a triangular testing approach. Operations from six beginners and six experts were assessed by three blinded-raters. Reliability and construct-validity were evaluated on a behaviorally anchored rating scale (highest score: 4) for the criteria: "instrument use", "tissue handling", "near misses and errors", and "end-product quality".

RESULTS

The model authentically mimicked an open median retromuscular mesh repair. Participants considered the procedure realistic. Reliability was excellent, ranging from 0.811 to 0.974 for "end-product quality", and "tissue handling" respectively. Construct-validity was confirmed with experts significantly outperforming beginners in the "use of instruments" (M_beg. = 2.33, M_exp. = 3.94, p < 0.001), "tissue handling" (M_beg. = 2.11, M_exp. = 3.72, p < 0.001), "near misses and errors" (M_beg. = 2.67, M_exp. = 3.67, p < 0.001), and "end-product quality" (M_beg. = 2.78, M_exp. = 3.72, p < 0.001). Criterion-validity revealed a paradox effect: beginners performed significantly better than experts (p < 0.05) when preparing the fatty triangle.

CONCLUSIONS

The model covers all relevant aspects involved in median-open retromuscular incisional hernia mesh repair. Performance differences between beginners and experts confirm construct-validity and thereby realism of the model. It enables to efficiently improve and practice technical skills of the demanding surgery.

Management of a primary ventral incisional hernia: a survey of the International Hernia Collaboration

A social media group, the International Hernia Collaboration (IHC), facilitates professional development among surgeons interested in hernia disease. The purpose of this study was to assess practice pattern differences among IHC surgeon members regarding a ventral incisional hernia (VIH) scenario. A single multiple-choice question, posted for 1 month on the IHC, assessed which operation was preferred for a healthy patient with a symptomatic, reducible primary VIH (5 × 6 cm). Responses were compared by surgeon practice location (US vs. World). In total, 371 IHC surgeons completed the survey. More respondents practicing in the US completed the survey (57.1% vs. 42.9%, P < 0.01). Respondents in the US cohort would select a robotic-assisted approach more frequently than World colleagues (47.6% vs. 8.8%, P < 0.01). More IHC surgeons in the US cohort would offer a robotic-assisted approach for primary VIH repair compared to World colleagues. Studies are warranted to investigate practice pattern differences related to VIH repair.

Does coagulopathy, anticoagulant or antithrombotic therapy matter in incisional hernia repair? Data from the Herniamed Registry

BACKGROUND

A considerable number of patients undergoing incisional hernia repair are on anticoagulant or antiplatelet therapy or have existing coagulopathy which may put them at higher risk for postoperative bleeding complications. Data about the optimal treatment of these patients are sparse. This analysis attempts to determine the rate of postoperative bleeding complications following incisional hernia repair and the consecutive rate of reoperation among patients with coagulopathy or receiving antiplatelet and anticoagulant therapy (higher risk group) compared to patients who do not have a higher risk (normal risk group).

METHODS

Out of the 43,101 patients documented in the Herniamed Registry who had an incisional hernia repair, 6668 (15.5%) were on anticoagulant or antithrombotic therapy or had existing coagulopathy. The implication of that higher risk profile for onset of postoperative bleeding was investigated in multivariable analysis. Hence, other influential variables were identified.

RESULTS

The rate of postoperative bleeding in the higher risk group was 3.9% (n = 261) and significantly higher compared to the normal risk group at 1.6% (n = 564) (OR 2.001 [1.699; 2.356]; p < 0.001). Additionally, male gender, use of drains, larger defect size, open incisional hernia repair, lower BMI, and higher ASA score significantly increased the risk of postoperative bleeding. The rate of reoperations due to postoperative bleeding was significantly increased in the higher risk group compared to the normal risk group (2.4 vs. 1.0%; OR 1.217 [1.071; 1.382]; p = 0.003). Likewise, the postoperative general complication rate (6.04 vs. 3.66%; p < 0.001) as well as the mortality rate (0.46 vs. 0.17%; p < 0.001) were significantly higher in the higher risk group.

CONCLUSIONS

Patients with anticoagulant or antiplatelet therapy or existing coagulopathy who undergo incisional hernia repair have a significantly higher risk for onset of postoperative bleeding. The risk of bleeding complications and complication-related reoperations seems to be lower after laparoscopic intraperitoneal onlay mesh.

IPOM: history of an acronym

IPOM has become a common term used by hernia surgeons. It refers to the treatment of a ventral hernia using an intraperitoneal placed mesh and most consider it an acronym for Intra-Peritoneal Onlay Mesh. Since intraperitoneal placement of mesh has fallen out of favor with some hernia surgeons and key-opinion-leaders recently, this might be the correct time to write down and preserve the history of this intriguing acronym.

The Treatment of Incisional Hernia

BACKGROUND

A meta-analysis of studies from multiple countries has shown that the incidence of incisional hernia varies from 4% to 10% depending on the type of operation. No epidemiological surveys have been conducted so far. The worst possible complication of an incisional hernia if it is not treated surgically is incarceration. In this article, we present the main surgical methods of treating this condition. We also evaluate the available randomized and controlled trials (RCTs) in which open and laparoscopic techniques were compared and analyze the patients' quality of life.

METHODS

We selectively searched PubMed for relevant literature using the search terms "incisional hernia" and "randomized controlled trial." 9 RCTs were included in the analysis. The endpoints of the meta-analysis were the number of reoperations, complications, and recurrences. The observed events were studied statistically by correlation of two unpaired groups with a fixed-effects model and with a random-effects model. We analyzed the quality of life in our.

RESULTS

Open surgery and laparoscopic surgery for the repair of incisional hernias have similar rates of reoperation (odds ratio [OR] 0.419 favoring laparoscopy, 95% confidence interval [0.159; 1.100]; p = 0.077). The rates of surgical complications are also similar (OR 0.706; 95% CI [0.278; 1.783]; p = 0.461), although the data are highly heterogeneous, and the recurrence rates are comparable as well (OR 1.301; 95% CI [0,761; 2,225]; p = 0.336). In our own patient cohort in Würzburg, the quality of life was better in multiple categories one year after surgery.

CONCLUSION

The operative treatment of incisional hernia markedly improves patients' quality of life. The currently available evidence regarding the complication rates of open and laparoscopic surgical repair is highly heterogeneous, and further RCTs on this subject would therefore be desirable. Moreover, new study models are needed so that well-founded individualized treatment algorithms can be developed.