Outcomes of redo-transversus abdominis release for abdominal wall reconstruction

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.

Parastomal hernia repair, trying to optimize the impossible reconstruction

PURPOSE

Parastomal hernias are a common and challenging problem with high rates of wound complications and hernia recurrence after repair. We present our approach to optimizing parastomal hernia repair through preoperative preparation, surgical approach, and postoperative management.

METHODS

Patients are carefully evaluated and optimized prior to surgery. Our typical surgical approach involves a generous midline laparotomy and retrorectus dissection followed by a posterior component separation with transversus abdominis release. We typically utilize a Sugarbaker technique for retromuscular mesh placement but also use the retromuscular keyhole or cruciate technique if there is insufficient bowel length.

RESULTS

Previously published results from our institution include wound complication rates of up to 16% after open retromuscular parastomal hernia repair. Stoma-specific complications, such as mesh erosion in the bowel, may be attributed to the mesh placement techniques. Hernia recurrence rates range from 11 to 30% up to 2 years postoperatively.

CONCLUSION

We prefer an open retromuscular approach with a Sugarbaker mesh configuration to treat complex parastomal hernias. However, wound morbidity and repair failure rates remain high, and additional research is needed to optimize surgical outcomes.

Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias

PURPOSE

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias.

METHODS

Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS).

RESULTS

Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100).

CONCLUSION

ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

Epidural analgesia and post-operative ileus after incisional hernia repair with transversus abdominis release: Results of a 5-year quality improvement initiative

INTRODUCTION

The optimal pain management strategy after open ventral hernia repair (VHR) with transversus abdominus release (TAR) is unknown. Opioids are known to have an inhibitory effect on the GI tract and cause postoperative ileus. Epidural analgesia is associated with lower postoperative ileus rates but may contribute to other postoperative complications. A propensity-matched retrospective review published by our group in 2018 found that epidural analgesia was associated with an increased length of stay and any postoperative complication after VHR. Epidural analgesia was therefore abandoned by our group following this publication. We aimed to determine if discontinuation of epidural analgesia affected ileus rates after open VHR.

METHODS

Patients who underwent open VHR with TAR from August 2014 to January 2022 ​at Cleveland Clinic Foundation with at least 30-day follow-up were retrospectively identified using the Abdominal Core Health Quality Collaborative registry. Patients with and without epidural analgesia were compared. The primary outcome was post-operative ileus. Additional outcomes included length of stay, deep venous thrombosis (DVT), pneumonia, wound complications and pain requiring intervention.

RESULTS

A total of 2570 patients were included: 420 had an epidural, 2150 did not. Preoperative patient and hernia characteristics were similar between both groups. Mean hernia width was 15.5 ​cm in the epidural group and 16.1 ​cm in the no epidural group. In the epidural group, ileus was seen in 9 of 420 (2.15%) of patients which was significantly less than in the no epidural group, 400 of 2150 (18.6%), p=>0.001. On multivariate analysis, epidurals were predictive of lower risk of ileus (OR 0.04, 95%CI 0.01-0.17, p ​= ​0.001) and pain requiring intervention (OR 0.02, 95%CI 0.00-0.71, p ​= ​0.02). Epidural analgesia was not associated with increased DVT rates, pneumonia, length of stay, SSI, or SSOPI.

DISCUSSION

Discontinuation of epidural analgesia was associated with a 9-fold increase in ileus rates after VHR with TAR. Epidurals may play an important role in limiting postoperative opioid use and therefore reducing risk of ileus. Other postoperative complications including pneumonia and venous thrombosis were not impacted by epidurals. Further prospective studies are needed to further define a ventral hernia patient population who will benefit from epidural analgesia.

Small bites versus large bites during fascial closure of midline laparotomies: a systematic review and meta-analysis

PURPOSE

Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing up to 60% at 3-5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH.

METHODS

We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%.

RESULTS

1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39-0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53-0.86; P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min; 95% CI 3.21-6.35; P < 0.001). No differences were seen regarding fascial dehiscence.

CONCLUSION

SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

Tipping the scale in abdominal wall reconstruction: An analysis of short- and long-term outcomes by body mass index

BACKGROUND

Morbid obesity, with a body mass index 35 kg/m2, is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes.

METHODS

Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh-to-hernia size ratio.

RESULTS

A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14-1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13-1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m2 group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02-1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year.

CONCLUSION

Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m2 should not be used to deny symptomatic patients abdominal wall reconstruction.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

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.

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.

Rectus to defect ratio for estimating the complexity of ventral hernia repair: Is it reliable for robotic surgery?

INTRODUCTION

The rectus to defect ratio (RDR) has been previously described as a metric which enables surgeons to estimate the need to perform additional myofascial release (AMR), in addition to open Rives-Stoppa retro-muscular hernia repair. We sought to validate this measurement specifically for patients undergoing robotic totally extraperitoneal (eTEP) hernia repair.

METHODS

A retrospective chart review of 188 patients who underwent robotic ventral hernia repair via eTEP approach. RDR on preoperative CT was compared to the final operation rendered. The primary endpoint was the RDR's ability to predict the need for TAR to achieve fascial closure.

RESULTS

Of 188 patients, 154 were repaired with rectus myofascial release, while 34 also required TAR. There was a linear decrease in the need for TAR with increasing RDR. RDR 1-1.49 (n ​= ​12) required TAR in 66.7 ​% of cases, RDR 1.5-1.99 (n ​= ​25) in 43.8 ​%, RDR 2-2.49 (n ​= ​31) in 29 ​%, and RDR >2.5 (n ​= ​151) in just 5.8 ​% CONCLUSION: The RDR accurately predicts the need for TAR to achieve fascial closure during robotic eTEP ventral hernia repair. An RDR >2.5 portends fascial closure without TAR 94.2 ​% of cases.

Outcomes of subsequent abdominal operations after an initial ventral hernia repair

INTRODUCTION

Nearly 20% of ventral hernia repair (VHR) patients require a subsequent abdominal operation (SAO), and mesh position may impact the complexity and outcome of the SAO.

METHODS

Retrospective review of VHR with mesh from 2006 to 2020 from an internal database and the ACHQC. Primary outcomes measured incidence, complexity, and complications of SAO relative to mesh position.

RESULTS

SAO was required in 433 of 2539 (17.1%) patients, totaling 671 operations; 197/893 (22.1%) with intraperitoneal mesh (IPM) and 236/1646 (14.3%) with extraperitoneal mesh (EPM; p ​< ​0.001). SAO was directly related to VHR in 180 (232 total SAOs) and unrelated in 253 (439 total SAOs). There were no significant differences in complications after SAO between IPM and EPM, nor any difference in adhesion complexity.

CONCLUSION

Incidence of SAO is higher with IPM, but surgical outcomes are similar. Due to the risk of secondary mesh infection with IPM, significantly more of these were removed at the time of SAO.

Mesh Selection in Abdominal Wall Reconstruction: An Update on Biomaterials

A wide array of mesh choices is available for abdominal wall reconstruction, making mesh selection confusing. Understanding mesh properties can make mesh choice simpler. Each mesh has characteristics that determine its durability, ability to clear an infection, and optimal position of placement in the abdominal wall. For clean retromuscular hernia repairs, we prefer bare, heavy weight, permanent synthetic mesh. For contaminated retromuscular abdominal wall reconstruction cases, such as parastomal hernia repairs, we typically use bare, medium weight, permanent synthetic mesh. Biologic and biosynthetic meshes also have acceptable wound event and hernia recurrence rates when used in contaminated cases.

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.

Ventral Hernia Repair: Does Mesh Position Matter?

Mesh positioning is a commonly discussed detail in ventral hernia repair and is often cited as a major contributor to the outcome of the operation. However, there is a paucity of data that establishes one plane as superior to others. In this article, we will provide an overview of all potential planes to place prosthetic material and review the relevant literature supporting each option and the complications associated with accessing each anatomic plane.

Recurrence after retromuscular repair or posterior components separation: How to address them. A retrospective multicentre cohort study

Abdominal wall hernias are common entities that represent important issues. Retromuscular repair and component separation for complex abdominal wall defects are considered useful treatments according to both short and long-term outcomes. However, failure of surgical techniques may occur. The aim of this study is to analyze results of surgical treatment for hernia recurrence after prior retromuscular or posterior components separation. We have retrospectively reviewed patient charts from a prospectively maintained database. This study was conducted in three different hospitals of the Madrid region with surgical units dedicated to abdominal wall reconstruction. We have included in the database 520 patients between December 2014 and December 2021. Fifty-one patients complied with the criteria to be included in this study. We should consider offering surgical treatment for hernia recurrence after retromuscular repair or posterior components separation. However, the results might be associated to increased peri-operative complications.

Long-term Clinical and Patient-Reported Outcomes After Transversus Abdominis Release With Permanent Synthetic Mesh: A Single Center Analysis of 1203 Patients

OBJECTIVE

We aimed to report long-term clinical and patient-reported outcomes of transversus abdominis release (TAR) with permanent synthetic mesh performed in a high-volume abdominal wall reconstruction practice.

SUMMARY BACKGROUND DATA

Despite increasing utilization of TAR in abdominal wall reconstruction, long-term clinical and patient-reported outcomes remain uncertain.

METHODS

Prospectively collected registry data from the Cleveland Clinic Center for Abdominal Core Health were analyzed retrospectively. Patients undergoing elective, open VHR with TAR and permanent synthetic mesh implantation between August 2014 and March 2020 with 30-day clinical and ≥1 year clinical or patient-reported outcome follow-up were included. Outcomes included composite hernia recurrence, characterized by patient-reported bulges and recurrent hernias noted on physical exam or imaging, as well as hernia-specific quality of life and pain.

RESULTS

A total of 1203 patients were included. Median age was 60 years [interquartile range (IQR): 52-67], median body mass index was 32 kg/m 2 (IQR: 28-36), median hernia width was 15 cm (IQR: 12-19), and 57% of hernias were recurrent. Fascial reapproximation was achieved in 92%. At a median follow-up of 2 years (IQR: 1-4), the overall composite hernia recurrence rate was 26%, with sensitivity analysis yielding best-case and worst-case estimates of 5% and 28%, respectively. Patients experienced improved hernia-specific quality of life and pain regardless of recurrence outcome; however, those who did not recur experienced more substantial improvement.

CONCLUSIONS

TAR with permanent synthetic mesh remains a valuable, versatile technique; however, surgeon and patient expectations should be tempered regarding long-term durability. Despite a high rate of recurrence, patients experience measurable improvements in quality of life.

The outcomes of open anterior component separation versus posterior component separation with transversus abdominis release for complex incisional hernias: a systematic review and meta-analysis

PURPOSE

The main objective was to assess the prevalence of hernia recurrence, wound complications (surgical site infections [SSI], seroma and hematoma) and mortality after anterior component separation (ACS) and posterior component separation via transversus abdominis muscle release (PCSTAR) in patients with complex incisional hernias. The so-called complex IH is a serious medical and societal challenge due to its direct and indirect costs; it is also hampered by the use of different surgical techniques, different type of meshes, and different results heterogeneously reported and interpreted. According to actual data, the best approach seems to be a mesh reinforcement component separation procedure augmented or not with an adjuvant technique (preoperative progressive pneumoperitoneum and/or Botulin toxin type A infiltration).

METHODS

A systematic search of four databases (MEDLINE, PubMed, Web of Science, and Google Scholars) was conducted to identify studies reporting on outcomes of component separation techniques and which were published before December 2021. A systematic review and a meta-analysis of postoperative outcomes were performed.

RESULTS

Nineteen studies including 3412 patients (1709 with ACS and 1703 with PCSTAR) were selected. Pooled hernia recurrence rate after a minimum 1-year follow-up was evaluated at 5.15% (odds ratio [OR] 0.68; 95% confidence interval [CI] 0.5-0.9; p = 0.0175). Pooled surgical site infection rate was 10.6% (OR 1.32; 95% CI 1.06-1.65; p = 0.0119). Seroma and hematoma were estimated at 9.75% (OR 1.93; 95% CI 1.52-2.44; p = 0.0001) and 3.83% (OR 1.81; 95% CI 1.26-2.61; p = 0.0012), respectively. ACS was associated with increased wound morbidity, seroma and hematoma. PCSTAR displayed higher recurrence rate (4.27% vs 6.11%).

CONCLUSIONS

PCSTAR was superior to ACS in terms of wound morbidity, surgical site infections, seroma and hematoma incidence. The procedure should be further evaluated in comparative head-to-head randomized controlled trials.

Surgeon accuracy and interrater reliability when interpreting CT scans after ventral hernia repair

BACKGROUND

Recurrent ventral hernia repair can be complex and requires a thorough understanding of prior interventions, myofascial releases, and location of prosthetic material. Without detailed operative reports, this information can be challenging to obtain, and some surgeons have suggested prior operative details can be discerned from radiographic imaging. We evaluated the accuracy and interrater reliability of surgeons to identify the type of prior VHR using CT imaging.

METHODS

Fifteen expert abdominal wall reconstruction surgeons individually reviewed 21 CT scans of patients after various VHR approaches and determined the approach from a multiple-choice selection. Negative controls (no prior laparotomy) and positive controls (laparotomy without VHR) were also included. Surgeon accuracy and interrater reliability were measured.

RESULTS

Surgeons were unable to identify the correct VHR over 50% of the time: open TAR and Rives-Stoppa were identified 42% of the time, open anterior component separation 24%, and robotic IPOM and eTEP 22% of the time, respectively. Surgeon interrater reliability, or agreement on answers-whether correct or incorrect-was fair (coefficient 0.23, p = 0.01).

CONCLUSIONS

Surgeons' ability to accurately identify the type of previous VHR using post-operative CT scans is poor. Without the knowledge of prior repairs, surgeons may find it difficult to choose the best reoperative approach, anticipate operative complexities, and schedule appropriate OR time. All of which guides patient counseling and expectations. This highlights the importance to accurately reflect VHR details in operative reports and use necessary resources to obtain operative reports, since surgeons cannot reliably use CT scans to identify prior repairs.

Hernia Sac Preservation for Prevention of Transversus Abdominis Release in Laparoscopic Extended-Totally Extra Peritoneal Repair of Ventral Hernia: A Minimalistic Solution for a Formidable Challenge

Background: Ventral hernia repair has always been an extensive and challenging surgery. The laparoscopic extended-Totally Extraperitoneal (E-TEP) technique of ventral hernia repair is gaining popularity due to the advantage of placing a large mesh in the retro rectus plane. When done through a Laparoscopic approach, the difficulty of the procedure is compounded by multiple factors such as obtaining retro muscular access, maintaining the retro muscular plane, crossing over to the contralateral retro muscular plane without entering intraperitoneally, suturing in a limited space, and manipulation of a large mesh in a constricted space for placement. In cases of large midline incisional hernias, dense adhesions to the previous surgical scar are often present. Despite having extremely satisfying outcomes, the aforementioned factors make the laparoscopic extended-total extraperitoneal repair of large midline ventral and incisional hernias an exceptionally challenging procedure. A tension-free midline approximation is the benchmark of ventral/incisional hernia surgery. In certain cases, this can be difficult to achieve due to multiple factors. For the purpose of attaining tension-free midline closure, component separation techniques (CST) have been explored and implemented. Of these, the posterior component separation technique of Transversus Abdominis Release (TAR) has gained popularity for reducing the tension of posterior rectus sheath during posterior midline closure in retro muscular repairs by adding a few centimetres of medial advancement. The main pitfall of TAR is its technical complexity, which may result in morbid complications when implemented incorrectly. Performing TAR laparoscopically compounds the complexity manyfold. Hence, to obviate the necessity to perform Laparoscopic TAR in cases of Laparoscopic E-TEP repair of large midline ventral and incisional hernias, we present that the technique of hernial sac preservation should be pre-emptively carried for all Laparoscopic ETEP repairs so that the necessity of performing TAR in select cases is reduced by aiding in the addition of final crucial centimetres of lengthening to the posterior rectus sheath for achieving posterior midline closure. This aids in the success of the procedure by preventing an additional complex procedure of TAR from being performed in an already challenging hernia repair technique of Laparoscopic E-TEP repair. Methods: We hereby report three cases of Ventral hernia repair in which Laparoscopic E-TEP repair was carried out and Hernial sac preservation technique was implemented successfully. Midline closure of the posterior rectus sheath was attained under reduced tension and a medium-weight macroporous polypropylene mesh was placed in the retro-rectus plane after measurement of the potential space. Patients were discharged uneventfully. Results: Patients were followed up for up to 6 months postoperatively and were found to have no complications. Conclusion: In Laparoscopic E-TEP repair of midline ventral hernias, preservation of the hernial sac along with the posterior rectus sheath might aid in the prevention of performing a TAR in selected cases where posterior layer tension is present. Hernia sac preservation thereby aids in reducing operative time and preventing potential morbid complications.