A call for standardization of wound events reporting following ventral hernia repair

Sequential surgeries following transversus abdominis release for abdominal wall reconstruction: Insights from a single-center analysis

INTRODUCTION

Abdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. Despite the popularity of the TAR procedure, current literature regarding post-AWR surgeries is limited. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind.

METHODS

Adult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence.

RESULTS

A total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% of the patients required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17-30 months, resulting in a 36.1% recurrent hernia diagnosis rate.

CONCLUSIONS

Abdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases.

Management of diastasis recti during ventral hernia repair: an analysis of the abdominal core health quality collaborative

PURPOSE

Advancements of minimally invasive techniques leveraged routine repair of concomitant diastasis recti (DR), as those approaches facilitate fascial plication and wide mesh overlap while obviating skin incision and/or undermining. Nevertheless, evidence on the value of such intervention is lacking. We aimed to investigate the management and outcomes of concomitant DR during ventral hernia repair (VHR + DR) from surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC).

METHODS

Patients who have undergone VHR + DR with a minimum 30-day follow-up complete were identified. Outcomes of interest included operative details, surgical site occurrences (SSO), medical complications, and readmissions.

RESULTS

169 patients (51% female, median age 46, median body mass index 31 kg/m2) were identified. Most hernias were primary (64% umbilical, 28% epigastric). Median hernia width was 3 cm (IQR 2-4) and median diastasis width and length were 4 cm (IQR 3-6) and 15 cm (IQR 10-20), respectively. Most operations were robotic (79%), with a synthetic mesh (92%) placed as a sublay (72%; 59% retromuscular, 13% preperitoneal). DR was repaired with absorbable (92%) and running suture (93%). Considering our cohort's relatively small diastasis and hernia size, a high rate of transversus abdominis release was noted (14.7%). 76% were discharged the same day and the 30-day readmission rate was 2% (2 ileus, 1 pneumonia). SSO rate was 4% (6 seromas, 1 skin necrosis) and only one patient required a procedural intervention.

CONCLUSIONS

ACHQC participating surgeons usually perform VHR + DR robotically with a retromuscular synthetic mesh and close the DR with running absorbable sutures. Short-term complications occurred in approximately 6% of patients and were mainly managed without interventions. Larger studies with longer-term follow-up are needed to determine the value of VHR + DR.

The impact of smoking on ventral and inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair.

SOURCE

A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma.

PRINCIPAL FINDINGS

Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes.

CONCLUSION

This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair.

PROSPERO REGISTRATION

ID CRD42024517640.

Use of a new vertical traction device for early traction-assisted staged closure of congenital abdominal wall defects: a prospective series of 16 patients

PURPOSE

Abdominal wall closure in patients with giant omphalocele (GOC) and complicated gastroschisis (GS) remains to be a surgical challenge. To facilitate an early complete abdominal wall closure, we investigated the combination of a staged closure technique with continuous traction to the abdominal wall using a newly designed vertical traction device for newborns.

METHODS

Four tertiary pediatric surgery departments participated in the study between 04/2022 and 11/2023. In case primary organ reduction and abdominal wall closure were not amenable, patients underwent a traction-assisted abdominal wall closure applying fasciotens®Pediatric. Outcome parameters were time to closure, surgical complications, infections, and hernia formation.

RESULTS

Ten patients with GOC and 6 patients with GS were included. Complete fascial closure was achieved after a median time of 7 days (range 4-22) in GOC and 5 days (range 4-11) in GS. There were two cases of tear-outs of traction sutures and one skin suture line dehiscence after fascial closure. No surgical site infection or signs of abdominal compartment syndrome were seen. No ventral or umbilical hernia occurred after a median follow-up of 12 months (range 4-22).

CONCLUSION

Traction-assisted staged closure using fasciotens®Pediatric enabled an early tension-less fascial closure in GOC and GS in the newborn period.

Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy.

METHODS

We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934).

RESULTS

We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09 min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation.

CONCLUSIONS

Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.

Robotic transversus abdominis release using HUGO RAS system: our initial experience

BACKGROUND

Transversus abdominis release (TAR) is an effective technique for treating large midline and off-midline hernias. Recent studies have demonstrated that robotic TAR (rTAR) is technically feasible and associated with improved outcomes compared to open surgery. There is no published experience to date describing abdominal wall reconstruction using the novel robotic platform HUGO RAS System (Medtronic®).

METHODS

All consecutive patients who underwent a rTAR in our institution were included. Three of the four arm carts of the HUGO RAS System were used at any given time. Each arm configuration was defined by our team in conjunction with Medtronic® personnel. rTAR was performed as previously described. Upon completion of the TAR on one side, a redocking process with different, mirrored arms angles was performed to continue with the contralateral TAR. Operative variables and early morbidity were recorded.

RESULTS

Ten patients were included in this study. The median BMI was 31 (21-40.6) kg/m2. The median height was 1.6 m (1.5-1.89 m). A trend of decreased operative time, console time, and redocking time was seen in these consecutive cases. No intraoperative events nor postoperative morbidity was reported. The median length of stay was 3 (1-6) days.

CONCLUSION

Robotic TAR utilizing the HUGO RAS system is a feasible and safe procedure. The adoption of this procedure on this novel platform for the treatment of complex abdominal wall hernias has been successful for our team.

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.

Outcomes of posterior sheath supplementation with Vicryl mesh in TAR-a single-center study

INTRODUCTION

In the Transversus Abdominis Release (TAR) procedure, ideally, the posterior sheath is completely reapproximated to establish an interface isolating the polypropylene mesh from visceral contents. When primary closure of the posterior sheath is unachievable, Vicryl mesh is commonly used to supplement the posterior sheath closure and an uncoated polypropylene mesh is placed superficial to the Vicryl mesh. The long-term implications of utilizing Vicryl mesh as an antiadhesive barrier are poorly understood. In this study, we aimed to assess our outcomes when utilizing Vicryl mesh to supplement the posterior sheath defects when placed underneath polypropylene mesh in patients undergoing posterior component separation.

METHODS

Adult patients who underwent VHR with concurrent TAR procedure with a permanent synthetic mesh and posterior sheath supplementation with Vicryl mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and December 2022 were queried retrospectively from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term mesh-related complications, and pragmatic hernia recurrence.

RESULTS

53 patients who underwent TAR procedure with posterior sheath supplementation using Vicryl mesh and had a minimum 12-month follow-up were identified. Of the 53 patients, 94.3% presented with recurrent hernias, 73.6% had a midline hernia, 7.5% had a flank hernia, and 18.9% had concurrent parastomal hernia. The mean hernia width was 24.9 cm (± 8.8 cm). No Vicryl mesh-related operative complications were identified in our study, with no instances of mesh erosion, fistulas, or interventions for small bowel obstruction. Skin necrosis requiring reoperations was observed in three patients (5.7%), leading to permanent mesh excision in two cases (3.8%) without intraabdominal visceral involvement. Throughout the 12-month follow-up, 23 incidences (43.4%) of surgical site occurrences (SSOs) and surgical site occurrences requiring procedural intervention (SSOPI) were documented.

CONCLUSIONS

Our findings suggest that posterior sheath supplementation with Vicryl mesh is a feasible approach to achieve posterior sheath closure in challenging abdominal wall reconstruction cases. Given the absence of notable mesh-related complications and a similar hernia recurrence rate to cases without posterior sheath supplementation, Vicryl mesh can be used to safely achieve posterior sheath closure in complex reconstructions with insufficient native tissue.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of complex abdominal wall reconstruction in patients with connective tissue disorders: a single center experience

INTRODUCTION

Individuals diagnosed with connective tissue disorders (CTD) are known to be predisposed to incisional hernia formation. However, there is a scarcity of data on outcomes for these patients undergoing hernia repair. We sought to describe our outcomes in performing abdominal wall reconstructions in these complex patients.

METHODS

Adult patients with CTD undergoing open, elective, posterior component separation with permanent synthetic mesh at our institution from January 2018 to October 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term hernia recurrence, and patient-reported quality of life.

RESULTS

Twelve patients were identified. Connective tissue disorders included Marfan's n = 7 (58.3%), Loeys-Dietz syndrome n = 2 (16.7%), Systemic Lupus Erythematosus n = 2 (16.7%), and Scleroderma n = 1 (8.3%). Prior incisions included three midline laparotomies and nine thoracoabdominal, mean hernia width measured 14 cm, and 9 were recurrent hernias. Surgical site occurrences (SSOs) were observed in 25% of cases, and 16.7% necessitated procedural intervention. All twelve patients were available for long-term follow-up, with a mean of 34 (12-62) months. There were no instances of reoperation or mesh excision related to the TAR procedure. One patient developed a recurrence after having his mesh violated for repair of a new visceral aneurysm. Mean HerQLes scores at 1 year were 70 and 89 at ≥ 2 years; Mean scaled PROMIS scores were 30.7 at 1 year and 36.3 at ≥ 2 years.

CONCLUSION

Ventral hernia repair with TAR is feasible in patients with connective tissue disorder and can be a suitable alternative in patients with large complex hernias.

Endoscopic-assisted repair of combined ventral hernias and diastasis recti: minimizing seroma incidence by quilting

BACKGROUND

To reduce the incidence of seromas, we have adapted the quilting procedure used in open abdominoplasty to the endoscopic-assisted repair of concomitant ventral hernia (VH) and diastasis recti (DR). The aim of this study was to describe the technique and assess its efficacy by comparing two groups of patients operated on with the same repair technique before and after introducing the quilting.

METHODS

This retrospective study included data prospectively registered in the French Club Hernie database from 176 consecutive patients who underwent surgery for concomitant VH and DR via the double-layer suturing technique. Patients were categorized into two groups: Group 1 comprised 102 patients operated before introducing the quilting procedure and Group 2 comprised 74 operated after introducing the quilting. To carry out comparisons between groups, seromas were classified into two types: type A included spontaneously resorbable seromas and seromas drained by a single puncture and type B included seromas requiring two or more punctures and complicated cases requiring reoperation.

RESULTS

The global percentage of seromas was 24.4%. The percentage of seromas of any type was greater in Group 1 (27.5%) than in Group 2 (20.3%). The percentage of Type B seromas was greater in Group 1 (19.6%) than in Group 2 (5.4%), when the percentage of Type A seromas was greater in Group 2 (14.9) than in Group 1 (7.9%). Differences were significant (p = 0.014). The operation duration was longer in Group 2 (83.9 min) than in Group 1 (69.9 min). Four complications requiring reoperation were observed in Group 1: three persistent seromas requiring surgical drainage under general anesthesia and one encapsulated seroma.

CONCLUSION

Adapting the quilting technique to the endoscopic-assisted bilayer suturing technique for combined VH and DR repair can significantly reduce the incidence and severity of postoperative seromas.

Evaluation of 30-day outcomes for open ventral hernia repair using self-gripping versus nonself-gripping mesh

BACKGROUND

The use of mesh is standard of care for large ventral hernias repaired on an elective basis. The most used type of mesh includes synthetic polypropylene mesh; however, there has been an increase in the usage of a new polyester self-gripping mesh, and there are limited data regarding its efficacy for ventral hernia. The purpose of the study is to determine whether there is a difference in surgical site occurrence (SSO), surgical site infection (SSI), surgical site occurrence requiring procedural intervention (SSOPI), and recurrence at 30 days after ventral hernia repair (VHR) using self-gripping (SGM) versus non-self-gripping mesh (NSGM).

METHODS

We performed a retrospective study from January 2014 to April 2022 using the Abdominal Core Health Quality Collaborative (ACHQC). We collected data on patients over 18 years of age who underwent elective open VHR using SGM or NSGM and whom had 30-day follow-up. Propensity matching was utilized to control for variables including hernia width, body mass index, age, ASA, and mesh location. Data were analyzed to identify differences in SSO, SSI, SSOPI, and recurrence at 30 days.

RESULTS

9038 patients were identified. After propensity matching, 1766 patients were included in the study population. Patients with SGM had similar demographic and clinical characteristics compared to NSGM. The mean hernia width to mesh width ratio was 8 cm:18 cm with NSGM and 7 cm:15 cm with SGM (p = 0.63). There was no difference in 30-day rates of recurrence, SSI or SSO. The rate of SSOPI was also found to be 5.4% in the nonself-gripping group compared to 3.1% in the self-gripping mesh group (p < .005). There was no difference in patient-reported outcomes at 30 days.

CONCLUSIONS

In patients undergoing ventral hernia repair with mesh, self-gripping mesh is a safe type of mesh to use. Use of self-gripping mesh may be associated with lower rates of SSOPI when compared to nonself-gripping mesh.

Analysis of retromuscular drain output and postoperative outcomes for heavyweight versus mediumweight polypropylene mesh following open ventral hernia repair

PURPOSE

Heavyweight polypropylene (HWPP) mesh is thought to increase inflammatory response and delay tissue integration compared to mediumweight (MWPP). Reactive fluid volume (i.e., drain output) may be a reasonable surrogate for integration. We hypothesized that daily drain output is higher with HWPP compared to MWPP in open retromuscular ventral hernia repair (VHR).

METHODS

This is a post-hoc analysis of a multicenter, randomized clinical trial conducted March 2017-April 2019 comparing MWPP and HWPP for VHR. Retromuscular drain output in milliliters was measured at 24-h intervals up to postoperative day seven. Univariate analyses compared differences in daily drain output and time to drain removal. Multivariable analyses compared total drain output and wound morbidity within 30 days and hernia recurrence at 1 year.

RESULTS

288 patients were included; 140 (48.6%) HWPP and 148 (51.4%) MWPP. Daily drain output for days 1-3 was higher for HWPP vs. MWPP (total volume: 837.8 mL vs. 656.5 mL) (p < 0.001), but similar on days 4-7 (p > 0.05). Median drain removal time was 5 days for both groups. Total drain output was not predictive of 30-day wound morbidity (p > 0.05) or hernia recurrence at 1 year (OR 1, p = 0.29).

CONCLUSION

While HWPP mesh initially had higher drain outputs, it rapidly returned to levels similar to MWPP by postoperative day three and there was no difference in clinical outcomes. We believe that drains placed around HWPP mesh can be managed similarly to MWPP mesh.

Evaluating the impact of lifting mandatory smoking cessation prior to elective abdominal wall reconstruction. A single-center experience

INTRODUCTION

Many studies identify active smoking as a significant risk factor for postoperative wound and mesh complications in patients undergoing abdominal wall reconstruction surgery. However, our group conducted an analysis using data from the ACHQC database, which revealed similar rates of surgical site infection (SSI) and surgical site occurrence requiring procedural intervention (SSOPI) between active smokers and non-smokers As a result, the Cl eveland Clinic Center for Abdominal Core Health instituted a policy change where active smokers were no longer subject to surgical delay. Our study aims to evaluate the impact of active smoking on the outcomes of these patients.

METHODS

We identified active smoking patients who had undergone open, elective, clean ventral hernia repair (VHR) with transversus abdominis release (TAR) and permanent synthetic mesh at Cleveland Clinic Foundation. Propensity matching was performed to create a 1:3 ratio of "current-smokers" and "never-smokers" and compared wound complications and all 30-day morbidity between the two groups.

RESULTS

106 current-smokers and 304 never-smokers were matched. Demographics were similar between the two groups after matching, with the exception of chronic obstructive pulmonary disease (COPD) (22.1% vs. 13.4%, p ​< ​.001) and body mass index (BMI) (31.1 vs. 32.6, p ​= ​.02). Rates of SSI (12.2% vs. 6.9%, p ​= ​.13), SSO (21.7% vs. 13.2%, p ​= ​.052), SSOPI (11.3% vs. 6.3%, p ​= ​.13), and reoperation (1.9% vs. 3.9%, p ​= ​.53) were not significantly different between active smokers and never-smokers correspondingly. One case (0.3%) of partial mesh excision was observed in the never-smokers group (p ​= ​1). The current-smokers group exhibited a significantly higher incidence of pneumonia compared to the never-smokers group (5.7% vs. 0.7%, p ​= ​.005).

CONCLUSION

Our study revealed that operating on active smokers did result in a slight increase in wound morbidity, although it did not reach statistical significance. Additionally, pulmonary complications were higher in the smoking group. Notably, we did not see any mesh infections in the smoking group during early follow up. We believe that this data is important for shared decision making on patients that are actively smoking contemplating elective hernia repair.

Age is just a number: The role of advanced age in predicting complications following ventral hernia repair with component separation

BACKGROUND

While advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear.

METHODS

A single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years).

RESULTS

Of 219 patients who underwent VHR with CST, 114 patients (52.1 ​%) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p ​= ​0.002) and COPD was positively associated with seroma development (OR 20.1, p ​= ​0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p ​= ​0.766).

CONCLUSIONS

VHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.

Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure

PURPOSE

Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application.

METHOD

A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated.

RESULTS

Imaging post-BTA revealed hernia width reduction of 1.9 cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1 cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%.

CONCLUSION

BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

Association of active smoking on 30-day wound events and additional morbidity and mortality following inguinal hernia repair with mesh: an analysis of the ACHQC database

BACKGROUND

To date, there is limited data on the association of active smoking and 30-day wound events following inguinal hernia repair (IHR) with mesh. We aimed to determine if active smoking at the time of IHR with mesh was associated with worse 30-days wound events and additional morbidity outcomes using the Abdominal Core Health Quality Collaborative (ACHQC) database.

METHODS

All adult patients undergoing elective, IHR with mesh who had 30-day follow-up data available were identified within the ACHQC database. Smokers were defined as having used nicotine within the 30 days prior to surgery. A 1:1 propensity score matched analysis was performed comparing smokers to non-smokers, controlling for factors previously shown to be associated with postoperative wound events. The effect of smoking on 30-day wound events and additional morbidity outcomes following IHR with mesh was investigated using Chi-square or Fisher's exact test for categorical data and Wilcoxon ranked test for continuous data.

RESULTS

A total of 17,543 patients met inclusion criteria; 1855 (11%) were active smokers at the time of minimally invasive IHR with mesh. A total of 3694 patients were used for the matched analysis. There were no statistically significant differences between the non-smokers and smokers with respect to the incidence of surgical site infection (p = 0.10), surgical site occurrences (p = 0.22), or surgical site occurrences requiring procedural intervention (p = 0.64). Non-smokers were significantly more likely to be readmitted to the hospital and had significantly less improvement in all pain domains following IHR with mesh.

CONCLUSIONS

Active smoking at the time of IHR with mesh is not associated with worse 30-day wound or additional morbidity and mortality outcomes. Based on these results, preoperative smoking cessation for all patients undergoing IHR may not reduce 30-day morbidity.

Surgical site occurrence after prophylactic use of mesh for prevention of incisional hernia in midline laparotomy: systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The use of mesh is the standard for the prevention of incisional hernia (IH). However, the effect of surgical site occurrence (SSO) has never been compared. The aim of this meta-analysis was to evaluate the prevalence of SSO and measure its negative effect through the calculation of the number needed to treat for net effect (NNT net).

METHODS

A meta-analysis was performed according to the PRISMA guidelines. The primary objective was to determine the prevalence of SSO and IH, and the secondary objective was to determine the NNT net as a metric to measure the combined benefits and harms. Only published clinical trials were included. The risk of bias was analyzed, and the random effects model was used to determine statistical significance.

RESULTS

A total of 15 studies comparing 2344 patients were included. The incidence of IH was significantly lower in the mesh group than in the control group, with an OR of 0.29 (95% CI 0.16-0.49, p = 0.0001). The incidence of SSO was higher in the mesh group than in the control group, with an OR of 1.21 (95% CI 0.85-1.72, p = 0.0001) but without statistical significance. Therefore, the way to compare the benefits and risks of each of the studies was done with the calculation of the NNT net, which is the average number of patients who need to be treated to see the benefit exceeding the harm by one event, and the result was 5, which is the average number of patients who need to be treated to see the benefit exceeding the harm by one event.

CONCLUSION

The use of mesh reduces the prevalence of IH and it does not increases the prevalence of SSO, the NNT net determined that the use of mesh continues to be beneficial for the patient.

Does a "hernia center" label provide better 30-day outcomes following elective ventral hernia repair?: An analysis of the ACHQC database

INTRODUCTION

Currently, there is no agreed upon definition of a designated hernia center (DHC) and no study has investigated the association of hernia center designation with ventral hernia repair (VHR) outcomes. We sought to investigate the current utilization of DHC and the association of hernia center designation with VHR outcomes.

METHODS

All patients who underwent elective, ventral hernia repair with mesh with 30-day follow-up from 2013 through 2020 were in the Americas Hernia Society Quality Collaborative (ACHQC) database. Patients were divided into two groups: those that underwent VHR at a DHC and those that underwent VHR at a non-designated hernia center site (NDHC). Using a 1:1 matched analysis, differences in the incidence of 30-day wound events, the total number of 30-day complications, one-year ventral hernia recurrence rates, and 30-day and one-year patient reported outcomes were compared between DHC and NDHC.

RESULTS

A total of 261 sites were included in our analysis; 78 (30%) were identified as DHC. After matching, there were 14,186 VHRs available for analysis. There was no significant difference in 30-day wound morbidity events. Patients who underwent VHR at NDHC were less likely to experience any 30-day complication or 1-year hernia recurrence while patients who underwent VHR at DHC had a statistically significant greater improvement in their HerQLes scores at one-year postoperatively.

CONCLUSIONS

There is currently no clear superiority to VHR at a DHC. The ACHQC may self-select for surgeons invested in hernia repair outcomes regardless of hernia center designation. More standardized criteria for a hernia center are required in order to positively influence the value of hernia care delivered in the United States.

[Incisional hernia: open abdominal wall reconstruction. Current state of the technique and results]

The treatment of complex midline hernias remains a particular challenge. The currently refined knowledge of the anatomy in the cadaver laboratory and advancing clinical experience have changed our present approach. The aim of this review is to present a description of the updated surgical procedures and outcomes. We favor the retromuscular or preperitoneal layer for mesh implantation, including the Rives-Stoppa procedure (sublay mesh) and posterior component separation with the Madrid modification. We operated on 334 complex midline incisional hernias: 6.3% retromuscular preperitoneal, 15% after Rives-Stoppa, 2.4% anterior component separation and 76% posterior component separation. A bridging procedure was used in 31%. A complication occurred in 35.3%, most of which were wound healing disorders (SSO). The average length of hospital stay was 7.2 days. We recorded a very low incidence of long-term complications: 3.3% recurrence, 0.9% chronic pain (daily use of pain medication), 6% bulging, 1.8% chronic seroma and 2.6% chronic mesh infection. Despite the associated morbidity, retromuscular/preperitoneal treatment offers excellent long-term results.

Surgical approaches for core abdominal injuries: a review of the Abdominal Core Health Quality Collaborative database

INTRODUCTION

Core abdominal injury (CAI) is a broad term that describes injuries resulting from repetitive loading of the pubis that leads to inflammation, rupture, or destabilization of the core muscles from the pubic bone. There is no clear recommendation on the surgical approach to CAI. We aimed to describe how hernia surgeons within the Abdominal Core Health Quality Collaborative (ACHQC) address this problem surgically and the short-term outcomes.

METHODS

We queried the ACHQC registry for patients undergoing surgery for isolated CAI and concomitant inguinal hernias (IH) and CAI. Operative approach and quality of life (using EuraHS survey scores) was abstracted.

RESULTS

A total of 29,451 patients underwent surgery for IHs, CAIs, or both within the registry. Twenty patients underwent surgery for isolated CAI (median age 29, 90% males). Eleven patients (55%) underwent surgery with mesh (four Lichtenstein, three TAPP, and four TEP). Nine patients (45%) underwent tissue-based repairs (four closure of floor, one Bassini, one McVay, one Shouldice, one femoral exploration, and one laparoscopic-to-open conversion). There were no postoperative complications or reoperations within 30 days. EuraHS scores showed improvement at 30 days from baseline (median 29 [6.75-41.75] from 42 [29.42-57.61]). Sixty patients had both IHs and CAIs (median age 31, 97% males). All patients received mesh. Thirty-one patients (52%) underwent open surgery (23 Lichtenstein, 1 plug, 7 TREPP) and 29 underwent minimally invasive repairs (23 TAPP, 6 TEP). There was one seroma at 30 days. EuraHS scores showed improvement at 30 days from baseline (median 16 [5.17-27.33] from 37.5 [26.44-46.58]).

CONCLUSIONS

Despite technical variability, CAIs with or without concomitant IH generally undergo operations commonly used for IH repairs. Within our series, there was inconsistency with approach and mesh placement. Future work should be focused on standardizing the approach to CAI and capturing long-term data within the ACHQC.

Robotic Enhanced-View Totally Extraperitoneal vs Intraperitoneal Onlay Mesh Evaluation: 1-Year Exploratory Outcomes of the REVEAL Randomized Clinical Trial

BACKGROUND

Patients with small- to medium-sized ventral hernias randomized to robotic enhanced-view totally extraperitoneal (eTEP) or robotic intraperitoneal onlay mesh (rIPOM) previously demonstrated comparable 30-day patient-reported outcomes. Here we report 1-year exploratory outcomes for this multi-center, patient-blinded randomized clinical trial.

STUDY DESIGN

Patients with midline ventral hernias 7 cm wide or less undergoing mesh repair were randomized to robotic eTEP or rIPOM. Planned exploratory outcomes at 1 year include pain intensity (using the Patient-Reported Outcomes Measurement Information System [PROMIS 3a]), Hernia-Related Quality of Life Survey (HerQLes) scores, pragmatic hernia recurrence, and reoperation.

RESULTS

One hundred randomized patients (51 eTEP, 49 rIPOM) reached a median 12-month follow-up (interquartile range 11 to 13) with 7% lost. After regression analysis adjusting for baseline scores, there was no difference in postoperative pain intensity at 1-year for eTEP compared with rIPOM (odds ratio [OR] 2.1 [95% CI 0.85 to 5.1]; p = 0.11). HerQLes scores were 15 points lower on average (ie less improved) at 1 year after eTEP repairs compared with rIPOM, a difference maintained after regression analysis (OR 0.31 [95% CI 0.15 to 0.67]; p = 0.003). Pragmatic hernia recurrence was 12.2% (6 of 49) for eTEP and 15.9% (7 of 44) for rIPOM (p = 0.834). In the first year, 2 eTEP and 1 rIPOM patients required reoperations related to their index repair (p = 0.82).

CONCLUSIONS

Exploratory analyses showed similar outcomes at 1 year in regard to pain, hernia recurrence, and reoperation. Abdominal wall quality of life at 1 year appears to favor rIPOM, and the possibility that an eTEP dissection is less advantageous in that regard should be the subject of future investigation.

Abdominal wound dehiscence and incisional hernia prevention in midline laparotomy: a systematic review and network meta-analysis

BACKGROUND

Incisional hernia (IH) is the main complication after laparotomy. In an attempt to reduce this complication, mesh techniques and studies in which the closure technique is modified have been proposed. Both types are characterized by comparison with the closure described as standard or conventional: 1 × 1, mass, and continuous closure. For this study, modified closure techniques (MCTs) were considered as those techniques in which an extra suture is placed (reinforced tension line (RTL), retention), the closure point is modified in distance (small bites) or shape (CLDC, Smead Jones, interrupted, Cardiff point) and which aim to reduce these complications. The objective of this network meta-analysis (NMA) was to evaluate the effectiveness of MCTs for reducing the incidence of IH and abdominal wound dehiscence (AWD) to provide objective support for their recommendation.

METHODS

An NMA was performed according to the PRISMA-NMA guidelines. The primary objective was to determine the incidence of IH and AWD, and the secondary objective was to determine the incidence of postoperative complications. Only published clinical trials were included. The risk of bias was analyzed, and the random-effects model was used to determine statistical significance.

RESULTS

Twelve studies comparing 3540 patients were included. The incidence of HI was lower in RTL, retention suture, and small bites, these techniques showed statistical differences with pooled ORs (95% CI) of 0.28 (0.09-0.83), 0.28 (0.13-0.62), and 0.44 (0.31-0.62), respectively. Associated complications, including hematoma, seroma, and postoperative pain, could not be analyzed; however, MCTs did not increase the risk of surgical site infection.

CONCLUSION

Small bites, RTL, and retention sutures decreased the prevalence of IH. RTL and retention suture decreased the prevalence of AWD. RTL was the best technique as it reduced both complications (IH and AWD) and had the best SUCRA and P-scores, and the number needed to treat (NNT) for net effect was 3.

REGISTRATION

This study was prospectively registered in the PROSPERO database under registration number CRD42021231107.

Ten-year outcomes following ventral hernia repair: making the case for better post-market surveillance in the USA

BACKGROUND

We sought to identify the 10-year complication and recurrence rates and associated sociodemographic and operative characteristics associated with non-mesh versus mesh-based ventral hernia repairs (VHRs).

METHODS

This was an IRB-approved (2020H0317) retrospective longitudinal study of patients undergoing mesh or non-mesh VHR from 2009-2019 at a single tertiary-care institution. The electronic medical record was used to collect sociodemographic, clinical, and intraoperative details, and early (≤ 30 days) and long-term (> 30-day) postoperative complications. Up to ten-year follow-up was obtained for long-term complications, categorized as: hernia recurrence reoperation (HRR), major complications requiring emergency surgery (MCES) (defined as non-elective operations related to the abdominal wall), and non-recurrence procedural intervention (NRPI) (defined as any procedures related to the abdominal wall, bowel, or mesh). Kaplan-Meier survival curves were obtained for each long-term complication.

RESULTS

Of the 645 patients identified, the mean age at index operation was 52.51 ± 13.57 years with 50.70% female. Of the index operations, 21.24% were for a recurrence. Procedure categories included: 57.36% incisional, 37.21% non-incisional umbilical, 8.22% non-incisional epigastric, 3.88% parastomal, 0.93% diastasis recti, and 0.47% Spigelian hernias. Operative approaches included open (n = 383), laparoscopic (n = 267), and robotic (n = 21). Fascial closure (81.55%) and mesh use (66.2%) were performed in the majority of cases. Median follow-up time was 2098 days (interquartile range 1320-2806). The rate of short-term complications was 4.81% for surgical site infections, 15.04% for surgical site occurrences, and 13.64% for other complications. At 10 years, the HRR-free survival probability was 85.26%, MCES-free survival probability was 94.44%, and NRPI-free survival probability was 78.11%.

CONCLUSIONS

A high proportion of patients experienced long-term recurrence and complications requiring intervention after index VHR. For many patients, a ventral hernia develops into a chronic medical condition. Improved efforts at post-market surveillance of operative approaches and mesh location and type should be undertaken to help optimize outcomes.

Systematic review and meta-analysis of the pre-operative application of botulinum toxin for ventral hernia repair

PURPOSE

Surgical repair of large hernia defects requires detailed pre-operative planning, particularly in cases with loss of domain. This situation often hampers mid-line reconstruction, even after component separation, when the size of the hernia is disproportional to the volume of the abdominal area. In this case, other strategies may be needed to place the viscera back into the abdominal cavity after reducing the hernia sac. The administration of botulinum toxin prior to the surgical procedure has been indicated as an adjunct for more complex cases. This results in stretching of the lateral musculature of the abdomen, allowing midline approximation. In addition, the application of botulinum toxin alone has been investigated as a means of downstaging in the management of ventral hernias, thereby precluding component separation and enabling primary closure of the midline by placement of mesh within the retromuscular space using the Rives Stoppa technique.

METHODS

Systematic review of the literature for observational studies involving patients undergoing pre-operative application of botulinum toxin for ventral hernia repair was conducted according to the PRISMA guidelines.

RESULTS

Advance of the lateral musculature of the abdomen by an average of 4.11 cm with low heterogeneity, as well as low rates of surgical site infection (SSI), surgical site occurrences (SSO) and recurrence, was shown.

CONCLUSION

Pre-operative application of botulinum toxin for ventral hernia repair promoted an increase in the length of the lateral musculature of the abdomen which can help improve the outcomes of morbidity and recurrence.

Optimal timing for antimicrobial prophylaxis to reduce surgical site infections: a retrospective analysis of 531 patients

It has been revealed that the administration of an antimicrobial prophylaxis (AP) reduces the rate of surgical site (SSI) following colorectal cancer surgery. Nevertheless, the optimal timing of this medication remains unclear. The aim of this study was to determine more precisely the optimal time for administering antibiotics and to see if this could reduce the number of possible surgical site infections. The files of individuals who underwent colorectal cancer surgery at the University Hospital Brandenburg an der Havel (Germany) between 2009 and 2017 were analyzed. Piperacillin/tazobactam, cefuroxime/metronidazole and mezlocillin/sulbactam were administered as AP regimens. Timing of AP was obtained. The primary objective was the rate of SSIs based on CDC criteria. Multivariate analysis took place to identify risk factors for SSIs. A total of 326 patients (61.4%) received an AP within 30 min, 166 (31.3%) between 30 and 60 min, 22 (4.1%) more than 1 h before surgery, and 15 (2.8%) after surgery. In 19 cases (3.6%) a SSI occurred during hospital stay. A multivariate analysis did not identify AP timing as a risk factor for the occurrence of SSIs. With significance, more surgical site occurrences (SSO) were diagnosed when cefuroxime/metronidazole was given. Our results suggest that AP with cefuroxime/metronidazole is less effective in reducing SSO compared with mezlocillin/sulbactam and tazobactam/piperacillin. We assume that the timing of this AP regimen of < 30 min or 30-60 min prior to colorectal surgery does not impact the SSI rate.

Short-term outcomes of robotic inguinal hernia repair during robotic prostatectomy - An analysis of the Abdominal Core Health Quality Collaborative

BACKGROUND

Concomitant robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR) has been reported. Nevertheless, data on its safety is lacking and some surgeons avoid performing both operations concurrently due to the potential risk of mesh related complications in the setting of a fresh vesicourethral anastomosis. We aimed to investigate differences in 30-day outcomes between patients undergoing RALP+RIHR and those undergoing RIHR alone.

METHODS

Patients who have undergone concomitant RALP and RIHR with 30-day follow-up available were identified within the Abdominal Core Health Quality Collaborative. Using a propensity score algorithm, they were matched with a cohort of patients undergoing RIHR alone based on confounders such as body mass index, age, ASA class, smoking, hernia size and recurrent status and prior pelvic operation. The groups were compared for 30-day rates of surgical site infection (SSI), surgical site occurrences (SSO), surgical site occurrences requiring operative intervention (SSOPI) and hernia recurrence.

RESULTS

24 patients underwent RALP + RIHR and were matched to 72 patients who underwent RIHR alone (3:1). Median age was 64 years, 33% were obese and 17% smokers. No significant differences were found on 30-day rates of overall complications (21% RALP + RIHR vs. 15% RIHR, p = 0.53) and surgical site occurrences (12% RALP + RIHR vs.11% RIHR, p = 0.85). No patient in the RALP + RIHR group had a 30-day SSI, SSOPI or early recurrence.

CONCLUSION

RALP+RIHR appears not to result in increased rates of wound complications, overall complications or early recurrence when compared to patient undergoing RIHR alone. Prospective, controlled studies with larger number of patients are needed to confirm our findings.

Endoscopic Anterior Component Separation and Transversus Abdominus Release are not Associated with Increased Wound Morbidity Following Retromuscular Incisional Hernia Repair

INTRODUCTION

Traditional anterior component separation during incisional hernia repair (IHR) is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence (SSO) compared to IHR without component separation (CS).

MATERIAL AND METHOD

This was a retrospective single-center cohort study of patients undergoing open retromuscular IHR comparing patients with or without the use of CS. Retromuscular mesh repair was performed in all patients, and CS was obtained by eACS or TAR. The primary outcome was 90-day incidence of postoperative SSO. Secondary outcomes included length of stay (LOS), 90-day readmission, 90-day reoperation rate and 3-year recurrence rate.

RESULTS

A total of 321 patients underwent retromuscular repair, 168 (52.3%) of whom received either eACS or TAR. The addition of eACS or TAR was associated neither with development of SSO (odds ratio: 1.80, 95% confidence interval: 0.94-3.46, P = 0.077) nor with hernia recurrence (hazard ratio 0.77, 0.26-2.34, P = 0.648). There was no significant difference between the groups regarding the frequencies of 90-day readmission or 90-day reoperation.

CONCLUSION

eACS or TAR as adjuncts to open retromuscular IHR were not associated with increased wound morbidity or hernia recurrence.

The external oblique muscle flap technique for the reconstruction of abdominal wall defects

PURPOSE

Several modifications to the anterior component separation technique (ACST) have been reported to facilitate the closure of abdominal wall defects. In this study, the external oblique (EO) muscle flap for modified ACST during major abdominal wall defect reconstructions has been described.

METHODS

A retrospective review of consecutive patients undergoing modified ACST was conducted. The clinical data were collected and retrospectively analyzed.

RESULTS

Among the 36 patients admitted to our hospital from December 2014 to December 2020, 9 cases had rectus abdominis tumors, 1 case had rectus abdominis trauma, and 26 cases had incisional hernias. The average age was 61.17 ± 13.76 years, and the mean BMI was 24.25 ± 3.18 kg/m². The average width of the defect was 14.33 ± 2.90 cm. Unilateral EO muscle flap technique was used to reconstruct the abdominal wall. 3 cases of surgical site infection (8.3%), 4 cases of grade III or IV seroma (11.1%) and 2 cases of intestinal obstruction (5.5%)were reported postoperatively. Ischemic necrosis of the abdominal EO muscle flap, incision dehiscence, intestinal fistula, or other complications were not observed. 1 case of incisional hernia recurrence (2.8%) was reported. Recurrence of tumors or abdominal wall bulging were not noted during the follow-up period of 32.53 ± 14.21 months.

CONCLUTIONS

The EO muscle flap technique is associated with low postoperative morbidity and recurrence rate, which approves it a reliable technique for selected groups of patients. Further research are needed to confirm the effectiveness of this technique.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

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

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

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

Reverse TAR may be added when necessary in open preperitoneal repair of lateral incisional hernias: a retrospective multicentric cohort study

BACKGROUND

The best approach for lateral incisional hernia is not known. Posterior component separation (reverse TAR) offers the possibility of using the retromuscular space for medial extension of the challenging preperitoneal plane. The aim of our multicenter study was to compare the operative and patient-reported outcomes measures (PROMs) using two open surgical techniques from the lateral approach: a totally preperitoneal vs a reverse TAR.

METHODS

A retrospective cohort study was performed since 2012 to 2020. Patients with lateral incisional hernia treated through a lateral approach were identified from a prospectively maintained multicenter database. Reverse TAR was added when the preperitoneal plane could not be safely dissected. The results obtained using these two lateral approaches were compared, including short- and long-term complications, as well as PROMs, using the specific tool EuraHSQoL.

RESULTS

A total of 61 patients were identified. Reverse TAR was performed in 33 patients and lateral retromuscular preperitoneal approach in 28 patients. Both groups were comparable in terms of sociodemographic and comorbidities variables. Surgical site occurrences occurred in 13 cases (21.3%), with 8 patients (13.1%) requiring procedural intervention. During a median follow-up of 34 months, no incisional hernia recurrence was registered. There was a case (1.6%) of symptomatic bulging that required reoperation. Also 12 patients (19.7%) presented an asymptomatic bulging. No statistically significant difference was identified in the complications and PROMs between the two procedures.

CONCLUSION

The open lateral retromuscular reconstruction using very large meshes that reach the midline has excellent long-term results with acceptable postoperative complications, including PROMs. A reverse TAR may be added, when necessary, without increasing complications and obtaining similar long-term results.

At least ninety days of follow-up are required to adequately detect wound outcomes after open incisional hernia repair

INTRODUCTION

Incisional hernia repair (IHR) carries a high risk of wound complications. Thirty-day outcomes are frequently used in comparative-effectiveness research, but may miss a substantial number of surgical site occurrences (SSO) including surgical site infection (SSI). The objective of this study was to determine an optimal length of follow-up to detect SSI after IHR.

METHODS

All adult patients undergoing open IHR at a single academic center over a 3 year period were reviewed. SSIs, non-infectious SSOs, and wound-related readmissions were recorded up to 180 days. The primary outcome was the proportion of SSIs detected at end-points of 30, 60, and 90 days of follow-up. Time-to-event analysis was performed for all outcomes at 30, 60, 90, and 180 days. Logistic regression was used estimate the relative risk of SSI for relevant risk factors.

RESULTS

A total of 234 patients underwent open IHR. Median follow-up time of 102 days. Overall incidence of SSI was 15.8% with median time to occurrence of 23 days. Incidence of non-infectious SSO was 33.2%, and SSO-related readmission was 12.8%. At 30, 60, and 90 days sensitivity was 81.6%, 89.5%, and 92.1 for SSI, and 46.7%, 76.7%, and 83.3% for readmission. In regression analysis, body mass index (RR 1.08, 95% CI 1.00, 1.15, p = 0.04) anterior component separation (RR 4.21, 95% CI 2.09, 6.34, p = 0.003), and emergency surgery (RR 3.25, 95% CI 1.47, 5.02, p = 0.01), were independently associated with SSI after adjusting for age, sex, contamination class, and procedure duration.

CONCLUSION

A considerable proportion of SSIs occurred beyond 30 days, but 90-day follow-up detected 92% of SSIs. Follow-up to 90 days captured only 83% of SSO-related readmissions. These results have implications for the design of trials evaluating wound complication after open IHR, as early endpoints may miss clinically relevant outcomes and underestimate the number needed to treat. Where possible, we recommend a minimum follow-up of 90 days to estimate wound complications following open IHR.

Retromuscular drain versus no drain in robotic retromuscular ventral hernia repair: a propensity score-matched analysis of the abdominal core health quality collaborative

BACKGROUND

Drains may be placed during robotic retromuscular ventral hernia repair (rVHR) to decrease wound morbidity, but their use is controversial. We aimed to assess the impact of retromuscular drain placement on wound morbidity after robotic rVHR.

METHODS

Patients with and without drains after robotic rVHR in the Abdominal Core Health Quality Collaborative (ACHQC) registry were compared using a propensity score-matched analysis. Outcomes included surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrences requiring procedural interventions (SSOPI) at 30 days.

RESULTS

Propensity score matching compared 580 patients with drains to 580 without drains. The groups were well matched with respect to hernia width (drain: 8.0 cm [IQR 6.0; 10.0] vs no drain: 8.0 cm [IQR 5.0; 10.0]; P = 0.399) and transversus abdominis release (drain: 409 (70.5%) vs no drain: 408 (70.3%); P = 0.949). At 30 days, patients with drains had fewer seromas than those without drains (22 (3.8%) vs 88 (15.2%); P < 0.0001). Rates of SSIs and SSOPIs were similar between the two groups at 30 days. Logistic regression analysis showed drain placement lowered the risk of an SSO compared to no drain placement (OR 0.32, CI 0.21-0.47; P < 0.0001). Hospital stay was longer for patients with drains than those without drains (2.0 days [IQR 1.0; 3.0] vs 1.0 day [IQR 1.0; 2.0], respectively; P < .0001).

CONCLUSION

Drain placement during robotic rVHR is associated with decreased postoperative seroma occurrence.

Prevalence of complicated surgical wounds and related factors among adults hospitalized in public hospitals

OBJECTIVE

To estimate the prevalence of complicated surgical wounds and its related factors in hospitalized adults.

METHOD

In this cross-sectional study, information from 251 patients hospitalized in seven public hospitals in Manaus, Brazil, and at risk of suffering surgical site complications after undergoing surgery was analyzed. Data were collected via interviews, physical examinations, and a medical record review from March to June 2015. Prevalence rate was estimated as the ratio between individuals with complications and patients at risk. To explore associated variables, individuals with and without complications were compared via 5% significant logistic regression and bivariate analyses. This study was approved by a research ethics committee.

RESULTS

Overall, 15 patients (6%) showed complicated surgical wounds. General hospitalization (p < 0.003), presence of ecchymosis, (p < 0.001), and men (p = 0.047) increased patients' probability of developing complications in 13.9, 10.1, and 8.2 times, respectively.

CONCLUSION

Assessing the prevalence of complicated surgical wounds and its associated factors in adults contributes to their epidemiological understanding, highlighting prevention targets and making data available for scientific comparisons.

Midterm Results of the Open and Minimally Invasive Transversus Abdominis Release Technique for the Treatment of Abdominal Wall Hernias in an Academic Center

Introduction: Large hernia defects are a challenge for general and specialized hernia surgeons. The transversus abdominis release (TAR) technique has revolutionized the treatment of complex hernias since it allows the closure of large midline hernias, as well as hernias in different locations. This study aims to report the experience with the TAR technique and mid-term results in the first 101 patients. Methods: Non-concurrent cohort review of our prospectively collected electronic database. All patients submitted to a TAR (open or minimally invasive eTEP-TAR) from 2017 to 2020 were included. Demographic data, comorbidities, hernia characteristics, preoperative optimization, intraoperative variables, and clinical outcomes were gathered. The main outcomes of this study are hernia recurrences and surgical morbidity. Results: A total of 101 patients were identified. The median follow-up was 26 months. Mean age and body mass index was 63 years and 31.4 Kg/m2, respectively. Diabetes was present in 22% of patients and 43% had at least one previous hernia repair. Nineteen patients had significant loss of domain. Mean hernia size and area were 13 cm and 247 cm2, respectively. Ninety-six percent of cases were clean or clean-contaminated. The mean operative time was 164 min and all patients received a synthetic mesh. We diagnosed two hernia recurrences and the overall (medical and surgical) complication rate was 32%. The hernia-specific complication rate was 17%, with seven surgical site infections and seven surgical site occurrences requiring procedural interventions. Notably, weight loss was associated with a lower risk of SSOPI and reoperations. Conclusion: We show an encouraging 2% of recurrences in the mid-term follow-up in the setting of clinically complex hernia repair. However, we observed a high frequency of overall and hernia-specific complications pointing to the complexity of the type of surgery itself and the patients we operated on.

The early outcomes of complex abdominal wall reconstruction with polyvinylidene (PVDF) mesh in the setting of active infection: a prospective series

PURPOSE

The use of synthetic mesh to repair infected abdominal wall defects remains controversial. Polyvinylidene fluoride (PVDF) mesh was introduced in 2002 as an alternative to polypropylene, with the advantages of improved biostability, lowered bending stiffness, and minimum tissue response. This study aimed to evaluate the short-term outcomes of using PVDF mesh to treat infected abdominal wall defects in the elective setting.

METHODS

This prospective clinical trial started in 2016 and was designed to evaluate the short- and mid-term outcomes of 38 patients submitted to abdominal wall reconstruction in the setting of active mesh infection and/or enteric fistulas (AI) when compared to a group of 38 patients submitted to clean ventral hernia repairs (CC). Patients were submitted to single-staged repairs, using onlay PVDF mesh (DynaMesh®-CICAT) reinforcement to treat their defects.

RESULTS

Groups had comparable demographic characteristics. The AI group had more previous abdominal operations and required a longer operative and anesthesia time. At 30 days, surgical site occurrences were observed in 16 (42.1%) AI vs. 17 (44.7%) CC, p = 0.817; surgical site infection occurred in 4 (10.5%) AI vs. 6 (15.8%) CC, p = 0.497; and a higher number of procedural interventions were required in the CC group, 15.8 AI vs. 28.9% CC, p = 0.169. Both groups did not have chronic infections at 1 year of follow-up, and one hernia recurrence was observed in the AI group.

CONCLUSIONS

The use of PVDF mesh in the infected setting presented favorable results with a low incidence of wound infection.

The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery

Background

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair.

Methods

A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible.

Results

From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants.

Conclusion

This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

Robotic vs Laparoscopic Ventral Hernia Repair with Intraperitoneal Mesh: 1-Year Exploratory Outcomes of the PROVE-IT Randomized Clinical Trial

BACKGROUND

Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have been demonstrated previously to have comparable 30-day outcomes in the PROVE-IT randomized clinical trial. Here we report our 1-year follow-up of enrolled patients to examine exploratory outcomes.

STUDY DESIGN

All patients enrolled in a previously published, registry-based, randomized trial investigating laparoscopic vs robotic ventral hernia repair with intraperitoneal mesh were reviewed. Several exploratory secondary outcomes were assessed: pain intensity (Patient-Reported Outcomes Measurement Information System [PROMIS 3a]), hernia-specific quality of life (Hernia-Specific Quality of Life Survey [HerQLes]), composite hernia recurrence, and reoperations.

RESULTS

A total of 95% (71 of 75) follow-up was achieved: 33 laparoscopic repairs and 38 robotic repairs. Median follow-up time was 12 months [interquartile range 10 to 12 months]. Following regression analysis adjusting for baseline scores, there was no difference in postoperative pain intensity at 1 year (p = 0.94). However, HerQLes scores increased by 12.0 more points following robotic repairs compared to laparoscopic counterparts (95% CI 1.3 to 22.7, p = 0.03). Composite hernia recurrence was 6% (2 of 33) for the laparoscopic cohort and 24% (9 of 38) for the robotic group (p = 0.04). There was no difference in rates of reoperation (p = 0.61).

CONCLUSIONS

Our exploratory analyses have identified potential differences in quality of life and recurrence, favoring the robotic and laparoscopic approaches, respectively. These findings warrant further study with larger patient cohorts to verify their potential significance.

Clinical outcomes of open abdominal wall reconstruction with the use of a polypropylene reinforced tissue matrix: a multicenter retrospective study

Objective

To assess mesh behaviour and clinical outcomes of open complex abdominal wall reconstruction (CAWR) with the use of a polypropylene reinforced tissue matrix.

Methods

A multicenter retrospective study of adult patients who underwent open CAWR with the use of a permanent polypropylene reinforced tissue matrix (OviTex^®) between June 2019 and January 2021.

Results

Fifty-five consecutive patients from four hospitals in the Netherlands were analysed; 46 patients with a ventral hernia and 9 patients with an open abdomen. Most patients with a ventral hernia had one or more complicating comorbidities (91.3%) and one or more complicating hernia characteristics (95.7%). Most procedures were performed in a (clean) contaminated surgical field (69.6% CDC 2–4; 41.3% CDC 3–4). All nine patients with an open abdomen underwent semi-emergent surgery. Twelve out of 46 patients with a ventral hernia (26.1%) and 4 of 9 patients with an open abdomen (44.4%) developed a postoperative surgical site infection that made direct contact with the mesh as confirmed on computed tomography (CT), suspicious of mesh infection. No patient needed mesh explantation for persistent infection of the mesh. During a median follow-up of 13 months, 4 of 46 ventral hernia patients (8.7%) developed a CT confirmed hernia recurrence.

Conclusion

Polypropylene reinforced tissue matrix can withstand infectious complications and provides acceptable mid-term recurrence rates in this retrospective study on open complex abdominal wall reconstructions. Longer follow-up data from prospective studies are required to determine further risk of hernia recurrence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-022-02604-y.

Long-term outcomes of seromas after ventral hernia repair: a propensity score-matched analysis of the Abdominal Core Health Quality Collaborative

PURPOSE

Seromas can occur after ventral hernia repairs (VHR), but little is known about their relevance to short- and long-term outcomes. We aimed to determine if there is a correlation between seroma occurrence after clean VHR with mesh and patient-reported and clinical outcomes.

METHODS

Patients with and without seromas in the Abdominal Core Health Quality Collaborative registry were compared using a propensity score-matched analysis. Outcomes included hospital readmissions, postoperative antibiotics use, and procedural interventions. Pain and hernia-related quality of life were assessed at 30 days and 1 year. Composite hernia recurrence rates were compared at 1 year.

RESULTS

Propensity score matching compared 218 patients with a seroma to 649 without a seroma. At 30 days, patients with seromas were more likely to be readmitted (27 (12%) vs 28 (4%), respectively; P < 0.001), receive postoperative antibiotics (25 (12%) vs 18 (3%), respectively; P < 0.001), and undergo procedural interventions (41 (19%) vs 23 (4%), respectively; P < 0.001) than patients without seromas. Surgical site occurrences were more common in patients with seromas than those without seromas at 1 year (12 (11%) vs 12 (4%), respectively; P = 0.01).Pain and hernia-related quality of life were similar for both groups at 30 days and 1 year. Composite hernia recurrence rates were similar for both groups at 1 year (37 seroma (17%) vs 115 no seroma (18%); P = 0.80).

CONCLUSION

Seromas after clean VHR with mesh were associated with short- and long-term morbidity, but they did not significantly impact quality of life or hernia recurrences at 1 year.

Comparing Sugarbaker versus keyhole mesh technique for open retromuscular parastomal hernia repair: study protocol for a registry-based randomized controlled trial

Background

Parastomal hernia, common after stoma creation, negatively impacts patient quality of life. For patients with a permanent stoma, durable parastomal hernia repair remains a challenge, with few high-quality studies for guidance. An alternative to open retromuscular parastomal hernia repair with retromuscular “keyhole” mesh is the recent Sugarbaker modification. We aim to compare these two techniques in a head-to-head prospective study.

Methods

This is a registry-based randomized controlled trial designed to investigate whether the retromuscular Sugarbaker technique is superior to the retromuscular keyhole technique for parastomal hernia repair. The primary study endpoint is parastomal hernia recurrence at 2 years. Secondary endpoints include hospital length-of-stay, readmission, wound morbidity, mesh-related complications, re-operation, all 30-day morbidity, and patient-reported outcomes, including hernia-related quality of life, stoma-specific quality of life, pain, and decision regret.

Discussion

Based on the post hoc analysis of a recent randomized controlled trial, we hypothesize that the retromuscular Sugarbaker technique will reduce parastomal hernia recurrence by 20% at 2 years compared to the retromuscular keyhole mesh technique. The results of this study may provide evidence-based guidance for surgeons repairing parastomal hernias.

Trial registration

ClinicalTrials.gov NCT03972553. Registered on 3 June 2019

Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial

IMPORTANCE

Biologic mesh is widely used for reinforcing contaminated ventral hernia repairs; however, it is expensive and has been associated with high rates of long-term hernia recurrence. Synthetic mesh is a lower-cost alternative but its efficacy has not been rigorously studied in individuals with contaminated hernias.

OBJECTIVE

To determine whether synthetic mesh results in superior reduction in risk of hernia recurrence compared with biologic mesh during the single-stage repair of clean-contaminated and contaminated ventral hernias.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, single-blinded randomized clinical trial was conducted from December 2012 to April 2019 with a follow-up duration of 2 years. The trial was completed at 5 academic medical centers in the US with specialized units for abdominal wall reconstruction. A total of 253 adult patients with clean-contaminated or contaminated ventral hernias were enrolled in this trial. Follow-up was completed in April 2021.

INTERVENTIONS

Retromuscular synthetic or biologic mesh at the time of fascial closure.

MAIN OUTCOMES AND MEASURES

The primary outcome was the superiority of synthetic mesh vs biologic mesh at reducing risk of hernia recurrence at 2 years based on intent-to-treat analysis. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrence requiring a procedural intervention, and 30-day hospital direct costs and prosthetic costs.

RESULTS

A total of 253 patients (median [IQR] age, 64 [55-70] years; 117 [46%] male) were randomized (126 to synthetic mesh and 127 to biologic mesh) and the follow-up rate was 92% at 2 years. Compared with biologic mesh, synthetic mesh significantly reduced the risk of hernia recurrence (hazard ratio, 0.31; 95% CI, 0.23-0.42; P < .001). The overall intent-to-treat hernia recurrence risk at 2 years was 13% (33 of 253 patients). Recurrence risk with biologic mesh was 20.5% (26 of 127 patients) and with synthetic mesh was 5.6% (7 of 126 patients), with an absolute risk reduction of 14.9% with the use of synthetic mesh (95% CI, -23.8% to -6.1%; P = .001). There was no significant difference in overall 2-year risk of surgical site occurrence requiring a procedural intervention between the groups (odds ratio, 1.22; 95% CI, 0.60-2.44; P = .58). Median (IQR) 30-day hospital direct costs were significantly greater in the biologic group vs the synthetic group ($44 936 [$35 877-$52 656] vs $17 289 [$14 643-$22 901], respectively; P < .001). There was also a significant difference in the price of the prosthetic device between the 2 groups (median [IQR] cost biologic, $21 539 [$20 285-$23 332] vs synthetic, $105 [$105-$118]; P < .001).

CONCLUSIONS AND RELEVANCE

Synthetic mesh demonstrated superior 2-year hernia recurrence risk compared with biologic mesh in patients undergoing single-stage repair of contaminated ventral hernias, and both meshes demonstrated similar safety profiles. The price of biologic mesh was over 200 times that of synthetic mesh for these outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02451176.

Risk Factors for Surgical Site Infection in the Undeserved Population After Ventral Hernia Repair: A 3936 Patient Single-Center Study Using National Surgical Quality Improvement Project

Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m² (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.

Prevalência de ferida operatória complicada e fatores associados em adultos internados em hospitais públicos

RESUMO Objetivo: Estimar a prevalência de Ferida Operatória Complicada e seus fatores associados, em adultos hospitalizados. Método: Estudo transversal, aprovado por comitê de ética. Foram analisadas informações de 251 pacientes submetidos à cirurgia e com risco de complicação do sítio cirúrgico, internados em sete hospitais públicos em Manaus (Brasil); cujos dados foram coletados por meio de entrevista, exame físico e revisão de prontuários, no período de março a junho de 2015. A taxa de prevalência foi calculada como a razão entre os indivíduos com complicação e os pacientes em risco. Para exploração de variáveis associadas, foram comparados indivíduos com e sem complicação por meio de análises bivariadas e regressão logística, com significância de 5%. Resultados: 15 pacientes (6%) apresentaram ferida operatória complicada. A presença de equimose (p < 0,001), ajustada pelo sexo masculino (p = 0,047) e a internação na clínica geral (p < 0,003) aumentaram a probabilidade de desenvolver a complicação em 10,1; 8,2 e 13,9 vezes, respectivamente. Conclusão A identificação da prevalência da ferida operatória complicada em adultos e seus fatores associados contribuem para a sua compreensão epidemiológica, destacando alvos de prevenção e disponibilizando dados para comparação científica.

Prophylactic negative pressure wound therapy for closed laparotomy incisions after ventral hernia repair: A systematic review and meta-analysis

PURPOSE

To evaluate the efficacy of prophylactic negative pressure wound therapy (pNPWT) in preventing surgical site infection (SSI), hernia recurrence and other wound complications following closed laparotomy incisions following ventral hernia repair (VHR).

METHODS

A comprehensive literature search of PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases was performed from inception until June 30, 2021, to identify all online English publications comparing the use of pNPWT with standard dressing for closed laparotomy incision following VHR.

RESULTS

One RCT and eleven retrospective cohort studies involving 1355 patients satisfied the basic inclusion criteria. The use of pNPWT reduced SSI (OR = 0.39 [95% CI: 0.24-0.62] P < 0.0001) and surgical site occurrence (SSO) (OR = 0.51 [95% CI: 0.27-0.98] P = 0.04). No statistically significant difference was detected in the incidence of hernia recurrence (OR = 0.61 [95% CI: 0.30-1.26] P = 0.18), seroma (OR = 0.70 [95% CI: 0.48-1.03]P = 0.07), hematoma (OR = 0.77 [95% CI: 0.33-1.81]P = 0.55) and wound dehiscence (OR = 0.68 [95% CI: 0.43-1.08]P = 0.10).

CONCLUSION

Use of pNPWT for closed laparotomy incisions following ventral hernia repair can significantly reduce the rate of postoperative surgical site infection (especially for superficial SIS) and surgical site occurrences. The number needed to treat (NNT) for preventing one occurrence of SSI is 9 patients. However, further research and more high quality studies are required to assess the effectiveness and assist in clarifying the role of pNPWT for closed laparotomy incisions following ventral hernia repair, preferentially in high-risk populations of developing SSI.

Controversies in Abdominal Wall Reconstruction

This article discuses current controversies in abdominal wall reconstruction, including the standardization of outcome reporting, mesh selection, the utility of robotic surgery in ventral hernia repair, and role for prophylactic stoma mesh at the time of permanent end colostomy formation. The current state of the literature pertaining to these topics is reviewed in detail.

Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields: Outcomes with Poly-4-Hydroxybutyrate Mesh

BACKGROUND

Hernia repair in the setting of contamination poses unique challenges, including complications such as recurrence and mesh infection. The ideal contaminated hernia repair including type of mesh use remains controversial. Poly-4-hydroxybutyrate is a biosynthetic scaffold for soft-tissue reinforcement and hernia repair and is potentially useful in contaminated hernia repair. The authors aim to describe postoperative outcomes, recurrence, and patient-reported outcomes after contaminated hernia repair with poly-4-hydroxybutyrate.

METHODS

Adult patients (≥18 years) undergoing a contaminated hernia repair with poly-4-hydroxybutyrate (Phasix) performed by a single plastic surgeon between January of 2015 and May of 2020 were identified. Patients with a ventral hernia defect and a Centers for Disease Control and Prevention wound class of II, III, or IV were included. Primary outcomes included recurrence, surgical-site infection, surgical-site occurrences, and surgical-site infection/occurrences requiring procedural interventions. As a secondary outcome, the authors assessed patient-reported outcomes as defined by the Abdominal Hernia-Q and Hernia-Related Quality of Life Survey.

RESULTS

Sixty patients were included with a median age of 52.5 and body mass index of 31 kg/m2. Median defect size was 300 cm2. Twenty-eight patients (46.7 percent) experienced a complication. The most common complications were surgical-site occurrence [n = 20 (33.3 percent)] and surgical-site infection [n = 10 (16.7 percent)]. Median follow-up was 24.2 months, with a recurrence rate of 8.3 percent (n = 4). Overall patient-reported outcomes improved postoperatively, and improvement was not affected by the presence of a complication.

CONCLUSIONS

Poly-4-hydroxybutyrateuse in contaminated hernia repair shows promising results with an acceptable safety profile. Although complications are frequent in this complex cohort, patient-reported outcomes improvement was significant even in patients with complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.