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

ENGINE-An EHS Project for Future Guidelines

Clinical guidelines are evidence-based recommendations developed by healthcare organizations or expert panels to assist healthcare providers and patients in making appropriate and reliable decisions regarding specific health conditions, aiming to enhance the quality of healthcare by promoting best practices, reducing variations in care, and at the same time, allowing tailored clinical decision-making. European Hernia Society (EHS) guidelines aim to provide surgeons a reliable set of answers to their pertinent clinical questions and a tool to base their activity as experts in the management of abdominal wall defects. The traditional approach to guideline production is based on gathering key opinion leader in a particular field, to address a number of key questions, appraising papers, presenting evidence and produce final recommendations based on the literature and consensus. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method offers a transparent and structured process for developing and presenting evidence summaries and for carrying out the steps involved in developing recommendations. Its main strength lies in guiding complex judgments that balance the need for simplicity with the requirement for complete and transparent consideration of all important issues. EHS guidelines are of overall good quality but the application of GRADE method, began with EHS guidelines on open abdomen, and the increasing adherence to the process, has greatly improved the reliability of our guidelines. Currently, the need to application of this methodology and the creation of stable and dedicated group of researchers interested in following GRADE in the production of guidelines has been outlined in the literature. Considering that the production of clinical guidelines is a complex process, this paper aim to highlights the primary features of guideline production, GRADE methodology, the challenges associated with their adoption in the field of hernia surgery and the project of the EHS to establish a stable guidelines committee to provide technical and methodological support in update of previously published guideline or the creation of new ones.

Early results of eTEP access surgery with preperitoneal repair of primary midline ventral hernias and diastasis recti. A 33 patient case series of "PeTEP"

BACKGROUND

This article aims to share the initial experience of the preperitoneal eTEP approach and its potential benefits in a selected group of patients. The eTEP Rives-Stoppa is a proven minimally invasive surgical technique for the treatment of ventral midline and off-midline hernias that has shown to be a solid, durable, and reproducible repair. The preperitoneal eTEP repair is a surgical technique that brings together the extraperitoneal access surgery with a preperitoneal repair for primary midline hernias avoiding posterior rectus sheath division and preservation of the retrorectus space while being able to treat simultaneous diastasis recti.

METHODS

The analysis included 33 patients operated with the preperitoneal eTEP approach from September 2022 to September 2023 in patients with primary small to medium (< 4 cm) midline hernias, single or multiple defects with or without diastasis recti. Age, gender, hernia characteristics, operative time, and surgical site occurrences will be discussed, as well as fine details and landmarks in the operative technique.

RESULTS

33 consecutive patients were operated, 19 female (57.5%) and 14 males (42.5%) between 32 and 63 years of age, the most common comorbidity found was obesity (BMI > 30). In 70% of the cases, operative time was 90 min ± 25 min. The average hospital stay was one day, while 12 went home the same day, and so far, no reoccurrences have been reported.

CONCLUSIONS

We believe the preperitoneal eTEP approach for small to medium primary midline hernias is an effective and solid repair that combines excellent features of proven surgical techniques and eliminates the need for posterior rectus sheath division while saving the retrorectus space, among other benefits that will be discussed. The reproducibility of the technique remains to be proven.

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.

Open vs. minimally invasive sublay incisional hernia repair. Is there a risk of overtreatment? EVEREG registry analysis

INTRODUCTION

Incisional hernia (IH) is a very common surgical procedure. Registries provide real world data. The objective is to analyze the open and minimally invasive (MIS) sublay technique (with or without associated components separation [CS]) in IH cases from the EVEREG registry and to evaluate the evolution over time of the techniques.

METHODS

All patients in EVEREG from July 2012 to December 2021 were included. The characteristics of the patients, IH, surgical technique, complications and mortality in the first 30 days were collected. We analyzed Group 1 (open sublay vs MIS sublay, without CS), Group 2 (open sublay vs MIS sublay, with CS) and Group 3 where the evolution of open and MIS techniques was evaluated over time.

RESULTS

4867 IH were repaired using a sublay technique. Group 1: 3739 (77%) open surgery, mostly midline hernias combined (P = .016) and 55 (1%) MIS, mostly lateral hernias (LH) (P = .000). Group 2: 1049 (21.5%) open surgery and 24 (0.5%) MIS. A meaningful difference (P = .006) was observed in terms of transverse diameters (5.9 (SD 2.1) cm for the MIS technique and 10.11 (SD 4.8) for the open technique). The LH MIS associated more CS (P = .002). There was an increase in the use of the sublay technique over time (with or without CS).

CONCLUSION

Increased use of the sublay technique (open and MIS) over time. For some type of hernia (LH) the MIS sublay technique with associated CS may have represented an overtreatment.

Protocol to develop a core outcome set in incisional hernia surgery: the HarMoNY Project

INTRODUCTION

Incisional hernia has an incidence of up to 20% following laparotomy and is associated with significant morbidity and impairment of quality of life. A variety of surgical strategies including techniques and mesh types are available to manage patients with incisional hernia. Previous works have reported significant heterogeneity in outcome reporting for abdominal wall herniae, including ventral and inguinal hernia. This is coupled with under-reporting of important clinical and patient-reported outcomes. The lack of standardisation in outcome reporting contributes to reporting bias, hinders evidence synthesis and adequate data comparison between studies. This project aims to develop a core outcome set (COS) of clinically important, patient-oriented outcomes to be used to guide reporting of future research in incisional hernia.

METHODS

This project has been designed as an international, multicentre, mixed-methods project. Phase I will be a systematic review of current literature to examine the current clinical and patient-reported outcomes for incisional hernia and abdominal wall reconstruction. Phase II will identify the outcomes of importance to all key stakeholders through in depth qualitative interviews. Phase III will achieve consensus on outcomes of most importance and for inclusion into a COS through a Delphi process. Phase IV will achieve consensus on the outcomes that should be included in a final COS.

ETHICS AND DISSEMINATION

The adoption of this COS into clinical and academic practice will be endorsed by the American, British and European Hernia Societies. Its utilisation in future clinical research will enable appropriate data synthesis and comparison and will enable better clinical interpretation and application of the current evidence base. This study has been registered with the Core Outcome Measures in Effectiveness Trials initiative.

PROSPERO REGISTRATION NUMBER

CRD42018090084.

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital

Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7 days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90 days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.

A modified Delphi process to establish research priorities in hernia surgery

BACKGROUND

Abdominal wall hernia repair is one of the most commonly performed surgical procedures worldwide, yet despite this, there remains a lack of high-quality evidence to support best management. The aim of the study was to use a modified Delphi process to determine future research priorities in this field.

METHODS

Stakeholders were invited by email, using British Hernia Society membership details or Twitter, to submit individual research questions via an online survey. In addition, questions obtained from a patient focus group (PFG) were collated to form Phase I. Two rounds of prioritization by stakeholders (phases II and III) were then completed to determine a final list of research questions. All questions were analyzed on an anonymized basis.

RESULTS

A total of 266 questions, 19 from the PFG, were submitted by 113 stakeholders in Phase I. Of these, 64 questions were taken forward for prioritization in Phase II, which was completed by 107 stakeholders. Following Phase II analysis, 97 stakeholders prioritized 36 questions in Phase III. This resulted in a final list of 14 research questions, 3 of which were from the PFG. Stakeholders included patients and healthcare professionals (consultant surgeons, trainee surgeons and other multidisciplinary members) from over 27 countries during the 3 phases.

CONCLUSION

The study has identified 14 key research priorities pertaining to abdominal wall hernia surgery. Uniquely, these priorities have been determined from participation by both healthcare professionals and patients. These priorities should now be addressed by well-designed, high-quality international collaborative research.

Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair

INTRODUCTION

The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes.

METHODS

A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre-optimization pathways were then compared with a recent Delphi consensus statement.

RESULTS

Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre-optimization and plan the definitive repair. These pre-optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well-defined referral criteria, perioperative high-risk management with pre-optimization, surgical planning, postoperative care and follow-up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness.

CONCLUSIONS

CAWH MDT can provide comprehensive, patient-centred care with improved postoperative outcomes. CQR are important to better evaluate long-term outcomes and ensure rigorous quality control.

Reporting guideline for interventional trials of primary and incisional ventral hernia repair

BACKGROUND

Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created.

METHODS

To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data.

RESULTS

The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected.

CONCLUSION

These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Wide variation in surgical techniques to repair incisional hernias: a survey of practice patterns among general surgeons

BACKGROUND

The purpose of this research was to examine the self-reported practice patterns of Canadian general surgeons regarding the elective repair of incisional hernias.

METHODS

A mail survey was sent to all general surgeons in Canada. Data were collected regarding surgeon training, years in practice, practice setting and management of incisional hernias. Surgeons were asked to describe their usual surgical approach for a patient with a midline incisional hernia and a 10 × 6 cm fascial defect.

RESULTS

Of the 1876 surveys mailed out 555 (30%) were returned and 483 surgeons indicated that they perform incisional hernia repair. The majority (62%) have been in practice > 10 years and 73% regularly repair incisional hernias. In response to the clinical scenario of a patient with an incisional hernia, 74% indicated that they would perform an open repair and 18% would perform a laparoscopic repair. Ninety eight percent of surgeons would use mesh, 73% would perform primary fascial closure and 47% would perform a component separation. The most common locations for mesh placement were intraperitoneal (46%) and retrorectus/preperitoneal (48%). The most common repair, which was reported by 37% of surgeons, was an open operation, with mesh, with primary fascial closure and a component separation.

CONCLUSIONS

While almost all surgeons who perform incisional hernia repairs would use permanent mesh, there was substantial variation reported in surgical approach, mesh location, fascial closure and use of component separation techniques. It is unclear how this variability may impact healthcare resources and patient outcomes.

The Grip Concept of Incisional Hernia Repair-Dynamic Bench Test, CT Abdomen With Valsalva and 1-Year Clinical Results

Incisional hernia is a frequent consequence of major surgery. Most repairs augment the abdominal wall with artificial meshes fixed to the tissues with sutures, tacks, or glue. Pain and recurrences plague at least 10-20% of the patients after repair of the abdominal defect. How should a repair of incisional hernias be constructed to achieve durability? Incisional hernia repair can be regarded as a compound technique. The biomechanical properties of a compound made of tissue, textile, and linking materials vary to a large extent. Tissues differ in age, exercise levels, and comorbidities. Textiles are currently optimized for tensile strength, but frequently fail to provide tackiness, dynamic stiction, and strain resistance to pulse impacts. Linking strength with and without fixation devices depends on the retention forces between surfaces to sustain stiction under dynamic load. Impacts such a coughing or sharp bending can easily overburden clinically applied composite structures and can lead to a breakdown of incisional hernia repair. Our group developed a bench test with tissues, fixation, and textiles using dynamic intermittent strain (DIS), which resembles coughing. Tissue elasticity, the size of the hernia under pressure, and the area of instability of the abdominal wall of the individual patient was assessed with low-dose computed tomography of the abdomen preoperatively. A surgical concept was developed based on biomechanical considerations. Observations in a clinical registry based on consecutive patients from four hospitals demonstrate low failure rates and low pain levels after 1 year. Here, results from the bench test, the application of CT abdomen with Valsalva's maneuver, considerations of the surgical concept, and the clinical application of our approach are outlined.

A systematic review of outcome reporting in incisional hernia surgery

Background

The incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies.

Methods

Literature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included.

Results

In total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used.

Conclusions

This review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

Adjunct botox to preoperative progressive pneumoperitoneum for incisional hernia with loss of domain: no additional effect but may improve outcomes

INTRODUCTION

Incisional hernia with loss of domain (IHLD) remains a surgical challenge. Its management requires complex approaches including specific preoperative and intra-operative techniques. This study focuses on the interest of adding preoperative botulinum toxin A (BTA) injection to preoperative progressive pneumoperitoneum (PPP), compared to PPP alone.

MATERIAL

Patients between January 2015 and March 2020 with IHLD who underwent pre-operative preparation were included. Their baseline characteristics were retrospectively analyzed, along with the characteristics of their incisional hernia before and after preparation including CT-scan volumetry. Intra-operative data, early post-operative outcomes, surgical site occurrences (SSOs) including surgical site infection (SSI) were recorded.

RESULTS

Four hundred and fifty (450) patients with incisional hernia were operated, including 41 patients (9.1%) with IHLD, 13 of which had both BTA and PPP, while 28 had PPP only. Both groups were comparable in term of patients and IHLD characteristics. Median increase in the volume of the abdominal cavity (VAbC) was + 55% for the entire population (+ 58.3% for the BTA-PPP group, p < 0.0001 and + 52.8% for the PPP-alone group, p < 0.0001) although the increase in volume was not different between the two groups (p = 0.99). Complete fascial closure was achieved in all patients. SSOs were more frequent in the PPP-alone group than in the BTA-PPP group (17 (60.7%) versus 3 (23.1%) patients, respectively, p = 0.043).

CONCLUSION

BTA and PPP are both useful in pre-operative preparation for IHLD. Combining both significantly increases the volume of abdominal cavity but associating BTA to PPP does not add any volumetric benefit but may decrease the post-operative SSO rate.

Linear versus volumetric CT analysis in predicting tension-free fascial closure in abdominal wall reconstruction

BACKGROUND

Improved outcomes of abdominal wall reconstruction (AWR) have been shown when tension-free fascial closure (TFFC) is achieved. Our objective was to determine the clinical and radiologic predictors of TFFC in patients undergoing AWR.

STUDY DESIGN

We conducted a single institution retrospective cohort study of adults who underwent AWR between 2007 and 2018. Demographics, hernia characteristics and operative data were collected. Linear and volumetric variables were obtained from preoperative abdominal CT scans, the latter following 3D reconstruction. Logistic regression was used to evaluate predictors of TFFC. Area under the curve (AUC) ≥ 0.70 was considered to have acceptable discrimination.

RESULTS

A total of 108 patients were eligible for analysis. The mean age was 57 ± 11 years and 53 (49%) were female. 42 (39%) hernias were recurrent, 10 (9%) patients had a stoma and 9 (8%) had a history of open abdomen. The mean defect width was 11 ± 4 cm and mean defect surface area was 150 ± 95 cm². The most common AWR technique was endoscopic component separation 75 (69%). TFFC was achieved in 90 (83%) patients. No demographics or 3D volumetric measures were predictive of TFFC (all AUC < 0.7). European hernia society (EHS) class M1 was predictive of failure of TFFC [AUC = 0.70; odds ratio 7.0 (referent M3); 95% confidence interval, 2.1-23.8]. Linear variables of rectus muscle separation were the most predictive of TFFC (AUC 0.73-0.77).

CONCLUSION

In contrast to clinical characteristics, radiologic characteristics of large incisional hernias requiring AWR are predictive of TFFC. In particular, EHS class M1 and linear variables of rectus muscle separation appear to be better predictors of TFFC than volumetric measurements.

INCISIONAL HERNIOPLASTY TECHNIQUES: ANALYSIS AFTER OPEN BARIATRIC SURGERY

BACKGROUND

Rives-Stoppa retromuscular technique: A) polypropylene mesh fixed on the posterior rectus sheath; B) rectus abdominal muscle; C) anterior rectus sheath being sutured. The best technique for incisional hernioplasty has not been established yet. One of the difficulties to compare these techniques is heterogeneity in the profile of the patients evaluated.

AIM

To analyze the results of three techniques for incisional hernioplasty after open bariatric surgery.

METHOD

Patients who underwent incisional hernioplasty were divided into three groups: onlay technique, simple suture and retromuscular technique. Results and quality of life after repair using Carolina's Comfort Scale were evaluated through analysis of medical records, telephone contact and elective appointments.

RESULTS

363 surgical reports were analyzed and 263 were included: onlay technique (n=89), simple suture (n=100), retromuscular technique (n=74). The epidemiological profile of patients was similar between groups. The onlay technique showed higher seroma rates (28.89%) and used a surgical drain more frequently (55.56%). The simple suture technique required longer hospital stay (2.86 days). The quality of life score was worse for the retromuscular technique (8.43) in relation to the onlay technique (4.7) and the simple suture (2.34), especially because of complaints of chronic pain. There was no difference in short-term recurrence.

CONCLUSION

The retromuscular technique showed a worse quality of life than the other techniques in a homogeneous group of patients. The three groups showed no difference in terms of short-term hernia recurrence.

Application of 3D reconstruction through CT to measure the abdominal cavity volume in the treatment of external abdominal hernia

OBJECTIVE

To evaluate 3D reconstruction through CT in the measurement of abdominal cavity volume.

METHODS

From January 1, 2019 to December 31, 2019, 61 patients diagnosed as external abdominal hernia were included in this prospective study. Multislice computed tomography (MSCT) was applied to patients scanning, and the images were transferred to post-processing workstation for further analysis. We measured the abdominal cavity volumes using volume rendering (VR) method and diameter rendering (DR) method, and the results were used to test whether there is a correlation between them. In addition, the time required for the measurement was recorded and analyzed.

RESULTS

In this study, we found that there was no significant difference in the abdominal cavity volumes between these two groups (VR vs. DR = 7857.316 ± 2035.786 cm³ vs. 7967.268 ± 2925.792 cm³, P > 0.05). Besides, the correlation analysis between the measured values of VR method and DR method showed there was a significant positive correlation (r = 0.922, P < 0.01). The linear regression equation based on the scatter plot was established as follows: y = 0.6417x + 2745, R² = 0.8504. Furthermore, this regression equation was simplified as follows: y = 0.64x + 2800, R² = 0.8499. Meanwhile, the time required for measurement of VR was significantly longer than that of DR (VR vs. DR = 64.3 ± 7.1 min vs. 2.6 ± 0.6 min, P < 0.01).

CONCLUSION

In conclusion, the DR method can quickly measure and calculate the abdominal cavity volume, and its accuracy can more suitable for clinical requirement.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Identifying critical computed tomography (CT) imaging findings for the preoperative planning of ventral hernia repairs

PURPOSE

Computed Tomography (CT) reports vary in qualitative detail and may not capture the information required for the preoperative planning of ventral hernia repairs. The goals of this study were to first survey general and hernia surgeons to establish key hernia imaging characteristics that should be included on CT reports and secondly, to retrospectively review preoperative CTs to determine the percentage that these same imaging characteristics are being reported.

METHODS

General and hernia surgeons were surveyed and asked to rank important hernia imaging factors as determined by two academic hernia surgeons on a Likert scoring scale. Additionally, preoperative abdominal/pelvic CT reports of patients who underwent a ventral hernia repair at a single academic institution were retrospectively reviewed for the presence of these imaging factors.

RESULTS

Fifty-one general and hernia surgeons responded to the survey. The most important imaging findings as determined by survey respondents were size of the hernia defect and presence of previous mesh. Additionally, 61% of respondents felt that the imaging report was less important than their own personal CT interpretation. Of the 257 preoperative CT reports reviewed, the number of defects was the most commonly reported factor (100%). The size of the defect and the presence of prior mesh was only included on 38% and 15% of reports, respectively.

CONCLUSIONS

CT reports vary in their reported imaging findings and often fail to include important preoperative hernia features. Future studies should aim to standardize imaging reports to better utilize CTs for the preoperative planning of abdominal wall reconstructions.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair

BACKGROUND

Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes.

METHODS

A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed.

RESULTS

Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes.

CONCLUSION

Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

A systematic review on surgical treatment of primary epigastric hernias

Objective

In this systematic review, we evaluated all literature reporting on the surgical treatment of primary epigastric hernias, primarily focusing on studies comparing laparoscopic and open repair, and mesh reinforcement and suture repair.

Methods

A literature search was conducted in Embase.com, PubMed and the Cochrane Library up to 24 April 2019. This review explicitly excluded literature on incisional hernias, ventral hernias not otherwise specified, and isolated (para)umbilical hernias. Primary outcome measures of interest were early and late postoperative complications.

Results

We obtained a total of 8516 articles and after a strict selection only seven retrospective studies and one randomised controlled trial (RCT) on treatment of primary epigastric hernia were included. In one study (RCT) laparoscopic repair led to less postoperative pain (VAS) compared to open repair (3.6 versus 2.4, p < 0.001). No significant differences in early postoperative complications and recurrences were observed. Mesh reinforcement was associated with lower recurrence rates than suture repair in two studies (2.2% versus 5.6%, p  = 0.001 and 3.1% versus 14.7%, p = 0.0475). This result was not sustained in all studies. No differences were observed in early postoperative complications after mesh or suture repair.

Conclusions

This review demonstrated that studies investigating surgical treatment of primary epigastric hernias are scarce. The best available evidence suggests that mesh reinforcement in primary epigastric hernia repair possibily leads to less recurrences and that laparoscopic repair leads to less postoperative pain. Due to the high risk of selection bias of included studies and heterogenic study populations, no clear recommendations can be conducted. High-quality studies with well-defined patient groups and clear endpoints, primarily focusing on primary epigastric hernias, are mandatory.

Electronic supplementary material

The online version of this article (10.1007/s10029-019-02017-4) contains supplementary material, which is available to authorized users.

What Exactly is Meant by "Loss of Domain" for Ventral Hernia? Systematic Review of Definitions

Large ventral hernias are a significant surgical challenge. "Loss of domain" (LOD) expresses the relationship between hernia and abdominal volume, and is used to predict operative difficulty and success. This systematic review assessed whether different definitions of LOD are used in the literature. The PubMed database was searched for articles reporting large hernia repairs that explicitly described LOD. Two reviewers screened citations and extracted data from selected articles, focusing on the definitions used for LOD, study demographics, study design, and reporting surgical specialty. One hundred and seven articles were identified, 93 full-texts examined, and 77 were included in the systematic review. Sixty-seven articles were from the primary literature, and 10 articles were from the secondary literature. Twenty-eight articles (36%) gave a written definition for loss of domain. These varied and divided into six broad groupings; four described the loss of the right of domain, six described abdominal strap muscle contraction, five described the "second abdomen", five describing large irreducible hernias. Six gave miscellaneous definitions. Two articles gave multiple definitions. Twenty articles (26%) gave volumetric definitions; eight used the Tanaka method [hernia sac volume (HSV)/abdominal cavity volume] and five used the Sabbagh method [(HSV)/total peritoneal volume]. The definitions used for loss of domain were not dependent on the reporting specialty. Our systematic review revealed that multiple definitions of loss of domain are being used. These vary and are not interchangeable. Expert consensus on this matter is necessary to standardise this important concept for hernia surgeons.

A systematic methodological review of non-randomised interventional studies of elective ventral hernia repair: clear definitions and a standardised minimum dataset are needed

BACKGROUND

Ventral hernias (VHs) often recur after surgical repair and subsequent attempts at repair are especially challenging. Rigorous research to reduce recurrence is required but such studies must be well-designed and report representative and comprehensive outcomes.

OBJECTIVE

We aimed to assesses methodological quality of non-randomised interventional studies of VH repair by systematic review.

METHODS

We searched the indexed literature for non-randomised studies of interventions for VH repair, January 1995 to December 2017 inclusive. Each prospective study was coupled with a corresponding retrospective study using pre-specified criteria to provide matched, comparable groups. We applied a bespoke methodological tool for hernia trials by combining relevant items from existing published tools. Study introduction and rationale, design, participant inclusion criteria, reported outcomes, and statistical methods were assessed.

RESULTS

Fifty studies (17,608 patients) were identified: 25 prospective and 25 retrospective. Overall, prospective studies scored marginally higher than retrospective studies for methodological quality, median score 17 (IQR: 14-18) versus 15 (IQR 12-18), respectively. For the sub-categories investigated, prospective studies achieved higher median scores for their, 'introduction', 'study design' and 'participants'. Surprisingly, no study stated that a protocol had been written in advance. Only 18 (36%) studies defined a primary outcome, and only 2 studies (4%) described a power calculation. No study referenced a standardised definition for VH recurrence and detection methods for recurrence varied widely. Methodological quality did not improve with publication year or increasing journal impact factor.

CONCLUSION

Currently, non-randomised interventional studies of VH repair are methodologically poor. Clear outcome definitions and a standardised minimum dataset are needed.

Increasing hernia size requires higher GRIP values for a biomechanically stable ventral hernia repair

Background

Increasing hernia sizes lead to higher recurrence rates after ventral hernia repair. A better grip might reduce the failure rates.

Material and methods

A biomechanical model delivering dynamic intermittent strain (DIS) was used to assess grip values at various hernia orifices. The model consists of a water-filled aluminium cylinder covered with tissues derived from pig bellies which are punched with a central defect varying in diameter. DIS was applied mimicking coughs lasting for up to 2 s with peak pressures between 180 and 220 mmHg and a plateau phase of 0.1 s. Ventral hernia repair was simulated with hernia meshes in the sublay position secured by tacks, glue or sutures as needed to achieve certain grip values. Grip was calculated taking into account the mesh: defect area ratio and the fixation strength. Data were assessed using non-parametric statistics.

Results

Using a mesh classified as highly stable upon DIS testing (DIS class A) a reduced overlap without fixation led to early slippage (p < 0.001). With the application of 16 fixation points, transmural sutures were better than tacks with Securestrap^® being better than Absorbatack^® (p < 0.001). Plotting the likelihood of a durable repair as a function of the calculated grip higher grip values were needed with increasing hernia diameter to achieve biomechanical stability. This is important for clinical work since the calculated grip values both from a registry and from published data tend to drop as hernia sizes increase indicating biomechanical instability.

Conclusion

The experimental work reported here demonstrates for the first time that higher grip values should be reached when repairing larger ventral hernias.

Use of imaging for pre- and post-operative characterisation of ventral hernia: systematic review

OBJECTIVE

Complex ventral hernia (CVH) repair is performed increasingly, exacerbated by the obesity epidemic. Imaging can characterise hernia morphology and diagnose recurrence. By systematic review we investigated the extent to which studies employ imaging.

METHODS

The PubMed database was searched for studies of ventral hernia repair from January 1995 to March 2016. Hernias of all size were eligible. Independent reviewers screened articles and extracted data from selected studies related to study design, use of pre- and post-operative hernia imaging and the proportion of subjects imaged. The review was registered: PROSPERO CRD42016043071.

RESULTS

15,771 records were identified initially. 174 full-texts were examined and 158 ultimately included in the systematic review [31 randomised controlled trials (RCTs); 32 cohort studies; 95 retrospective cohort studies]. 31,874 subjects were reported overall. Only 19 (12%) studies employed pre-operative imaging for hernia characterisation and 46 (29%) post-operatively [equating to 511 (2%) of all pre-operative subjects and 1123 (4%) post-operative]. Furthermore, most studies employing imaging did not do so in all subjects: Just 6 (4%) of the 158 studies used imaging in all subjects pre-operatively and just 4 (3%) post-operatively, i.e. imaging was usually applied to a proportion of patients only. Moreover, the exact proportion was frequently not specified. Studies using imaging frequently stated that "imaging", "radiography" or "radiology" was used but did not specify the modality precisely nor the proportion of subjects imaged.

CONCLUSION

Despite the ability to characterise ventral hernia morphology and recurrence with precision, most indexed studies do not employ imaging. Where imaging is used, data are often reported incompletely. Advances in knowledge: (1) This systematic review is the first to focus on the use of imaging in surgical studies of ventral hernia repair. (2) Studies of ventral hernia repair rarely use imaging, either to characterise hernias pre-operatively or to diagnose recurrence, despite the latter being the primary outcome of most studies. (3) Failure to use imaging will result in incomplete hernia characterisation and underestimate recurrence rates in studies of surgical repair.

What Is the Current Knowledge About Sublay/Retro-Rectus Repair of Incisional Hernias?

Introduction: There continues to be very little agreement among experts on the precise treatment strategy for incisional hernias. That is the conclusion drawn from the very limited scientific evidence available on the repair of incisional hernias. The present review now aims to critically assess the data available on the sublay/retro-rectus technique for repair of incisional hernia. Materials and Methods: A systematic search of the literature was performed in May 2018 using Medline, PubMed, and the Cochrane Library. This article is based on 77 publications. Results: The number of available RCTs that permit evaluation of the role of the sublay/retro-rectus technique in the repair of only incisional hernia is very small. The existing data suggest that the sublay/retro-rectus technique has disadvantages compared with the laparoscopic IPOM technique for repair of incisional hernia, but in that respect has advantages over all other open techniques. However, the few existing studies provide only a limited level of evidence for assessment purposes. Conclusion: Further RCTs based on a standardized technique are urgently needed for evaluation of the role of the sublay/retro-rectus incisional hernia repair technique.

Imaging complex ventral hernias, their surgical repair, and their complications

Abstract

Complex ventral hernia (CVH) describes large, anterior, ventral hernias. The incidence of CVH is rising rapidly due to increasing laparotomy rates in ever older, obese and co-morbid patients. Surgeons with a specific interest in CVH repair are now frequently referring these patients for imaging, normally computed tomography scanning. This review describes what information is required from preoperative imaging and the surgical options and techniques used for CVH repair, so that radiologists understand the postoperative appearances specific to CVH and are aware of the common complications following surgery.

Key Points

• Complex ventral hernia (CVH) describes large abdominal wall hernias (e.g. width ≥10cm).

• CVH patients are being referred increasingly for preoperative and postoperative imaging.

• Imaging is pivotal to characterise preoperative morphology and quantify loss of domain.

• Postoperative imaging appearances are contingent on the surgical methods used for CVH repair.

• Postoperative complications are depicted easily by imaging.