Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese

Descriptive Analysis of Outcomes After Onlay Ventral Hernia Repair in Obese Patients

OBJECTIVE

To determine outcomes after on lay large ventral hernia repair in obese patients.

INTRODUCTION

Large ventral hernia repairs (VHR) in obese patients remain a challenge. Obesity is a risk factor for intraoperative difficulties and postoperative complications. Recurrence rates after VHR in obese patients range between 12-50% versus 10% in nonobese patients. While results of laparoscopic techniques in VHR compare favorably to open, outcomes in correlation with obesity, technique, and defect size are less understood.

METHODS

A single surgeon's experience of 329 consecutive VHR between 2013-2022 was retrospectively reviewed. Inclusion criteria were obesity (BMI >30) and large hernia defects (>5 cm). A modified onlay technique was used which included component release and a lightweight monofilament polypropylene mesh. Primary outcome measures were hernia recurrence and wound complications.

RESULTS

A total of 56 patients met inclusion criteria. Patients were majority male (n=30, 54%), with a median age of 58.5 years (inter quartile range (IQR) 33-83), and median BMI of 36 kg/m2 (IQR: 30-72). Median hernia defect size was 8 cm (IQR: 5-15). Twenty patients had undergone prior mesh repairs. Median follow-up was 52 months (IQR: 6 months-9 years). Two patients experienced recurrence (3.6%) and four experienced wound complications (four seromas, one panniculitis, 8.9%). No patients suffered flap ischemia or necrosis.

CONCLUSION

Obesity is a risk factor for poor outcomes after VHR. We developed a protocol for obese patients with large defects involving a modified onlay technique which demonstrates comparable results to other VHR techniques in obese patients.

Chronic postsurgical pain (CPSP): an underestimated problem after incisional hernia treatment

BACKGROUND

Chronic postsurgical pain (CPSP) is a potential long-term problem following open incisional hernia repair which may affect the quality of life of patients despite successful anatomical repair of the hernia. The aim of this manuscript was to identify the incidence and outcome of patients following open incisional hernia repair in respect of risk factors to develop CPSP.

METHODS

A single-center retrospective analysis of patients who underwent open incisional hernia repair between 2015 and 2021 was performed. Pre-existing conditions (e.g., diabetes mellitus and malignancy), hernia complexity, postoperative complications, and postoperative pain medication were analyzed using the local database. Quality of life and CPSP were assessed using the EuraHS Quality of Life (QoL) questionnaire.

RESULTS

A total of 182 cases were retrospectively included in a detailed analysis based on the complete EuraHS (QoL) questionnaire. During the average follow-up period of 46 months, this long-term follow-up revealed a 54.4% incidence of CPSP and including a rate of 14.8% for severe CPSP (sCPSP) after open incisional hernia surgery. The complexity of the hernia and the demographic variables were not different between the group with and without CPSP. Patients with CPSP reported significantly reduced QoL. The analgesics score which includes the need of pain medication in the initial days after surgery was significantly higher in patients with CPSP than in those without (no CPSP: 2.86 vs. CPSP: 3.35; p = 0.047).

CONCLUSION

The presence of CPSP after open incisional hernia repair represents a frequent and underestimated long-term problem which has been not been recognized to this extent before. CPSP impairs QoL in these patients. Patients at risk to develop CPSP can be identified in the perioperative setting by the need of high doses of pain medication using the analgesics score. Possibly timely adjustment of pain medication, even in the domestic setting, could alleviate the chronicity or severity of CPSP.

Component separation and large incisional hernia: predictive factors of recurrence

PURPOSE

To clarify the factors related to recurrence after component separation technique (CST).

MATERIALS AND METHODS

A retrospective study was conducted of 381 patients who underwent CST between May 2006 and May 2017 at a tertiary center. All patients had a transverse hernia defect grade W3 in EHS classification. Recurrence rate was determined by clinical examination plus confirmation by abdominal CT scan.

RESULTS

At a median of 61.6 months of postoperative follow-up, we reported 34 cases of hernia recurrence (8.9%). On multivariate analysis, BMI > 30 (OR 2.20; CI 1.10-3.91, p = 0.031), immunosuppressive drug use (OR 1.06 CI 1.48-2.75, p = 0.003) and development of surgical site infection (OR 2.7; CI 1.53-4.01, p = 0.002) were factors of recurrence after CST. There was no difference in recurrence rate among repairs of primary and recurrent hernias, urgent repair, operative time, type of prosthesis, or concomitant procedures, even planned or unplanned enterotomies.

CONCLUSION

Obesity (BMI > 30), immunosuppressive drug use, and postoperative wound infections were predictors of recurrence after CST.

Repair of lumbar incisional hernia using polypropylene mesh strip sutures - A case report

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Lumbar incisional hernias are rare type of hernias constituting about 1.5% of all ventral hernias.

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Diagnosis is mainly through symptoms corelated with the CT scan findings.

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Repair of these lateral hernias is challenging due to its proximity to the 12 rib and iliac bone.

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Use of mesh strip sutures is a newer concept and may be an effective way to repair lumbar incisional hernias.

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Mesh sutures have demonstrated better resistance to suture pull-through when compared to conventional polypropylene sutures.

Introduction

Lumbar hernias are considered rare and they constitute less than 1.5% of all abdominal wall hernias.

Case report

Here we present a case of a 72-year-old female with a left flank swelling since 2-years diagnosed as a lumbar incisional hernia. This lumbar incisional hernia1 was repaired successfully using polypropylene mesh strip sutures.2

Discussion

Many surgical techniques have been described for repair of LIH. Suture repair, mesh repair and myofascial flaps have been described for lumbar hernias. Repairing a lumbar hernia can be surgically challenging because of its proximity to bony structures, which can limit proper dissection and mesh overlap. We performed defect closure with PMSS. Patient has no recurrence after 2 years of follow up.

Conclusion

In our case of left lumbar incisional hernia, defect closure with PMSS was an effective operation. This technique may also be effective in potentially contaminated settings due to reduced implant load. Further studies are required to understand its biomechanics and long-term outcomes.

Early versus delayed complex abdominal wall reconstruction with biologic mesh following damage-control surgery

BACKGROUND

Damage-control surgery for trauma and intra-abdominal catastrophe is associated with a high rate of morbidities and postoperative complications. This study aimed to compare the outcomes of patients undergoing early complex abdominal wall reconstruction (e-CAWR) in acute settings versus those undergoing delayed complex abdominal wall reconstruction (d-CAWR).

METHOD

This study was a pooled analysis derived from the retrospective and prospective database between the years 2013 and 2019. The outcomes were compared for differences in demographics, presentation, intraoperative variables, Ventral Hernia Working Grade (VHWG), US Centers for Disease Control and Prevention wound class, American Society of Anesthesiologists (ASA) scores, postoperative complications, hospital length of stay, and readmission rates. We performed Student's t test, χ2 test, and Fisher's exact test to compare variables of interest. Multivariable linear regression model was built to evaluate the association of hospital length of stay and all other variables including the timing of complex abdominal wall reconstruction (CAWR). A p value of <0.05 was considered significant.

RESULTS

Of the 236 patients who underwent CAWR with biological mesh, 79 (33.5%) had e-CAWR. There were 45 males (57%) and 34 females (43%) in the e-CAWR group. The ASA scores of IV and V, and VHWG grades III and IV were significantly more frequent in the e-CAWR group compared with the d-CAWR one. Postoperatively, the incidence of surgical site occurrence, Clavien-Dindo complications, comprehensive complication index, unplanned reoperations, and mortality were similar between the two groups. Backward linear regression model showed that the timing of CAWR (β = -11.29, p < 0.0001), ASA (β = 3.98, p = 0.006), VHWG classification (β = 3.62, p = 0.015), drug abuse (β = 13.47, p = 0.009), and two comorbidities of cirrhosis (β = 12.34, p = 0.001) and malignancy (β = 7.91, p = 0.008) were the significant predictors of the hospital length of stay left in the model.

CONCLUSION

Early CAWR led to shorter hospital length of stay compared with d-CAWR in multivariable regression model.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Ventral hernia repair in bariatric patients

Morbid Obesity is increasing worldwide at fast pace with associated co-morbidities also on the rise. Considering that Obesity is one of the main risk factors for developing a Ventral Hernia this will results that in the future we will experience a rise in those hernia in patients undergoing any abdominal surgery. There is no clarity on the best timing and choice for procedures. We are well aware also on the difficulties in hernia repair surgery and the relative outcome so adding obesity as co-factors amplify the challenges. In fact, today both general surgeons with expertise in abdominal wall repair and bariatric surgeons are faced with a new dilemma: the obese patient with an abdominal wall hernia. This article will briefly review the impact of obesity on the natural history of hernia, its associated complication, management strategies and outcome.

Outcomes of Open Retro-Rectus Hernia Repair With Mesh in Obesity Class III

BACKGROUND

Abdominal wall hernias continue to be one of the most common general surgery pathologies. Patients with an elevated body mass index (BMI) are routinely counseled about weight loss before elective repair. However, a definitive BMI "cutoff" has not been established. Here, we report our experience with open retro-rectus hernia repair (ORRHR) with mesh in patients with a BMI over 40 kg/m², and we attempt to determine if a BMI "cutoff" can be established.

METHODS

Data from patients undergoing ORRHR with mesh at Geisinger Medical Center from January 1, 2014, to December 31, 2018, were collected and retrospectively analyzed.

RESULTS

Cohorts were composed of 2 groups, BMI ≥ 40 kg/m² (n = 117) and BMI < 40 kg/m² (n = 90). All patients underwent an elective ORRHR with mesh. Operative time increased significantly as the patient's BMI increased (P ≤ .01). Patients in the higher BMI group had a significantly higher rate of surgical site infections (SSIs) (8.55% vs. 1.1%, P = .018). Higher BMI did not translate to a higher recurrence rate.

CONCLUSIONS

Patients undergoing ORRHR with mesh who had a BMI over 40 kg/m² had an increased risk of SSI and longer operative time, possibly suggesting a potential association other than SSI and BMI. More studies are needed to determine if BMI is indeed correlated with hernia recurrence and if BMI should influence the decision to undergo repair.

Systematic review of transversus abdominis release in complex abdominal wall reconstruction

BACKGROUND

Transversus abdominis release (TAR), as a type of posterior component separation, is a new myofascial release technique in complex ventral hernia repair. TAR preserves rectus muscle innervation, creates an immense retromuscular plane and allows bilaminar ingrowth of the mesh. The place of the TAR within the range of established anterior component separation techniques (CST) is unclear. Aim of this systematic literature review is to estimate the position of the TAR in the scope of ventral hernia repair techniques.

METHODS

MEDLINE, Embase, Pubmed and the Cochrane controlled trials register and Science citation index were searched using the following terms: 'posterior component separation', 'transversus abdominis release', 'ventral hernia repair', 'complex abdominal wall reconstruction'. To prevent duplication bias, only studies with a unique cohort of patients who underwent transversus abdominis release for complex abdominal wall reconstruction were eligible. Postoperative complications and recurrences had to be registered adequately. The rate of surgical site occurrences and recurrences of the TAR were compared with those after anterior CST, published earlier in two meta-analyses.

RESULTS

Five articles met our strict inclusion criteria, describing 646 TAR patients. Methodological quality per study was good. Mean hernia surface was 509 cm² and 88% of the hernias were located in the midline. Preoperative risk stratification was distributed in low risk (10%), co-morbid (55%), potentially contaminated (32%) and infected (3%). Pooled calculations demonstrated a mean SSO rate of 15% after TAR (20-35% after anterior CST) and a mean 2-year hernia recurrence rate of 4% (13% after anterior CST). Mean hernia surface was 300 cm² in anterior component separation studies.

CONCLUSION

This review demonstrates that the transversus abdominis release is a good alternative for anterior CST in terms of SSO and recurrence, especially in very large midline ventral hernias.

A randomized controlled experimental study comparing chitosan coated polypropylene mesh and Proceed™ mesh for abdominal wall defect closure

BACKGROUND

Abdominal wall defects and hernias are commonly repaired with synthetic or biological materials. Adhesions and recurrences are a common problem. A study was conducted to compare Chitosan coated polypropylene mesh and a polypropylene-polydioxanone composite with oxidized cellulose coating mesh (Proceed™) in repair of abdominal wall defect in a Rabbit hernia model.

METHODS

A randomized controlled experimental study was done on twelve New Zealand white rabbits. A ventral abdominal defect was created in each of the rabbits. The rabbits were divided into two groups. In one group the defect was repaired with Chitosan coated polypropylene mesh and Proceed mesh™ in the other. The rabbits were operated in two phases. They were followed up at four weeks and twelve weeks respectively after which the rabbits were sacrificed. They were evaluated by open exploration and histopathological examination. Their efficacy in reducing adhesion and ability of remodeling and tissue integration were studied.

RESULTS

There was no statistical significance in the area of adhesion, the force required to remove the adhesions, tissue integration and remodeling between Chitosan and Proceed™ group. Histological analysis revealed that the inflammatory response, fibrosis, material degradation and remodeling were similar in both the groups. There were no hernias, wound infection or dehiscence in any of the studied animals.

CONCLUSION

Chitosan coated polypropylene mesh was found to have similar efficacy to Proceed™ mesh. Chitosan coated polypropylene mesh, can act as an anti adhesive barrier when used in the repair of incisional hernias and abdominal wall defects.

Quality of Life after Ventral Hernia Repair with Endoscopic Component Separation Technique

Background and Aims:

Large ventral hernias are often associated with physical, social, and health problems for the patient, and surgical repair remains a challenge. Open components separation has widely been applied to obtain closure of the midline and recently a minimally invasive technique has been introduced (endoscopic components separation). The effectiveness and safety of endoscopic components separation have been demonstrated in previous reports, whereas little is known about quality of life in these patients. With a focus on quality of life, we present the first patients from our center operated on with endoscopic components separation.

Material and Methods:

A total of 19 consecutive patients scheduled for open hernia repair with endoscopic components separation from October 2010 to June 2012 were included. All procedures included endoscopic components separation because of the hernia size. Demographic data, operative information, and postoperative complications were recorded. All patients completed two similar questionnaires regarding their function level, cosmetic satisfaction, analgesic medication, alcohol consumption, and self-estimated physical and mental health before and after the hernia repair. Patients were assessed as outpatient median 2 months and 16 months after operation for exclusion of hernia recurrence and completion of the postoperative questionnaire.

Results and Conclusions:

Operating room time was median 204 min and correlated significantly with the hernia size. A total of 21 postoperative complications occurred in 14 patients. The length of stay was median 6 days and correlated significantly with duration of the operation. Of these, 15 patients participated in late follow-up visit. Two patients experienced recurrent hernias. Postoperative function level, cosmetic satisfaction, and self-estimated physical and mental health improved significantly. Alcohol consumption was significantly reduced. Endoscopic components separation is a reliable method to repair large ventral hernias, although further studies are required to determine the exact benefits for endoscopic components separation hernia repair versus conventional hernia repair.

Critical analysis of Strattice performance in complex abdominal wall reconstruction: intermediate-risk patients and early complications

The purpose of this study was to analyze the performance of a porcine-derived acellular dermal matrix (Strattice Reconstructive Tissue Matrix) in patients at increased risk for perioperative complications. We reviewed medical records for patients with complex abdominal wall reconstruction (AWR) and Strattice underlay from 2007 to 2010. Intermediate-risk patients were defined as having multiple comorbidities without abdominal infection. Forty-one patients met the inclusion criteria (mean age, 60 years; mean body mass index, 35.5 kg/m(2)). Comorbidities included coronary artery disease (63.4%), diabetes mellitus (36.6%), and chronic obstructive pulmonary disease (17.1%). Fascial closure was achieved in 40 patients (97.6%). Average hospitalization was 6.4 days (range, 1-24 days). Complications included seroma (7.3%), wound dehiscence with Strattice exposure (4.9%), cellulitis (2.4%), and hematoma (2.4%). All patients achieved abdominal wall closure with no recurrent hernias or need for Strattice removal. Patients with multiple comorbidities at intermediate risk of postoperative complications can achieve successful, safe AWR with Strattice.

Endoscopic versus open component separation: systematic review and meta-analysis

BACKGROUND

The component separation technique (CST) was developed to improve the integrity of abdominal wall reconstruction for large, complex hernias. Open CST necessitates large subcutaneous skin flaps and, therefore, is associated with significant ischemic wound complications. The minimally invasive or endoscopic component separation technique (MICST) has been suggested in preliminary studies to reduce wound complication rates post-operatively. In this study, we systematically reviewed the literature comparing open versus endoscopic component separation and performed a meta-analysis of controlled studies.

METHODS

A comprehensive search of electronic databases was completed. All English, randomized controlled trials, non-randomized comparison study, and case series were included. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias tools.

RESULTS

63 primary studies (3,055 patients) were identified; 7 controlled studies and 56 case series. The total wound complication rate was lower for MICST (20.6 %) compared to Open CST (34.6 %). MICST compared to open CST was shown to have lower rates of superficial infections (3.5 vs 8.9 %), skin dehiscence (5.3 vs 8.2 %), necrosis (2.1 vs 6.8 %), hematoma/seroma formation (4.6 vs 7.4 %), fistula tract formation (0.4 vs 1.0 %), fascial dehiscence (0.0 vs 0.4 %), and mortality (0.4 vs 0.6 %.) The open component CST did have lower rates of intra-abdominal abscess formation (3.8 vs 4.6 %) and recurrence rates (11.1 vs 15.1 %). The meta-analysis included 7 non-randomized controlled studies (387 patients). A similar suggestive overall trend was found favoring MICST, although most types of wound complications did not show to significance. MICST was associated with a significantly decreased rate of fascial dehiscence and was shown to be significantly shorter procedure.

CONCLUSION

This systematic review and meta-analysis comparing MICST to open CST suggests MICST is associated with decreased overall post-operative wound complication rates. Further prospective studies are needed to verify these findings.

Laparoscopic component separation reduces postoperative wound complications but does not alter recurrence rates in complex hernia repairs

BACKGROUND

The purpose of this study was to evaluate and compare the incidence of wound complications after laparoscopic component separation (LCS) vs open component separation (OCS) in patients with complex abdominal wall hernias.

METHODS

A retrospective review was performed of all patients who underwent LCS or OCS for repair of a complex abdominal wall hernia at a single institution between 2009 and 2011. Charts were reviewed to identify postoperative wound complications. A computed tomographic scan or physical examination was used for the determination of hernia recurrence. Categoric variables were compared using the Fisher exact test. Univariate and multivariate analyses were performed using linear and Cox regression. Recurrence rates were compared using log-rank tests (Kaplan-Meier method).

RESULTS

A total of 44 patients underwent LCS (n = 18) or OCS (n = 26). There was no statistically significant difference between categoric variables. Multivariate analysis using wound complications as the dependent variable showed a statistically significantly lower rate of wound complications in the LCS group.

CONCLUSIONS

LCS is associated with a lower rate of wound complications when compared with OCS but yields comparable recurrence rates.

The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese

BACKGROUND

Because of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure.

METHODS

We performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m(2). The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up.

RESULTS

Mean patient age was 53 years (range 32-75 yr) with mean BMI of 46 kg/m(2) (range 41-60 kg/m(2)). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively.

CONCLUSION

The PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.

A modified approach to component separation using biologic graft as a load-sharing onlay reinforcement for the repair of complex ventral hernia

BACKGROUND

Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure.

METHODS

This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences.

RESULTS

There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation.

CONCLUSIONS

This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.

Hybrid ventral hernia repair: technique and results

BACKGROUND

Open and laparoscopic approaches to ventral hernia repair are generally exclusive of each other. However, select patients with difficult hernias may benefit from combined open/laparoscopic hybrid techniques to avoid dissection of large subcutaneous flaps.

METHODS

Seven patients underwent combined laparoscopic and open approaches for ventral hernia repair. Records were reviewed for technical details, demographics, hernia and mesh characteristics, and postoperative outcomes.

RESULTS

Two hybrid techniques were used: (1) initial laparoscopic approach converted to open adhesiolysis followed by totally laparoscopic mesh fixation and (2) open repair and adhesiolysis with laparoscopic-assisted mesh fixation. In the first approach, after conversion to open adhesiolysis, mesh with four quadrant sutures was placed intraabdominally. Pneumoperitoneum was re-established, and the mesh was fixed laparoscopically with sutures and tacks in standard fashion. For the second hybrid approach, after hernia reduction and adhesiolysis, mesh was anchored with sutures placed at 3-4 cm intervals with a Reverdin needle and further secured posteriorly with a hernia tacker over 180° circumference. Prior to tying the contralateral transfascial sutures, two 5-mm laparoscopic ports were placed lateral to the mesh under direct vision on the opposite side. Once the facial sutures were tied, pneumoperitoneum was established, and the contralateral side of mesh was tacked laparoscopically. Mean patient age was 65 years and BMI 38. Mean defect size was 10.6 cm × 8.3 cm and mean mesh size was 25 cm × 19 cm. Operative time was 318 min (210-405 min). Hospital stay was 5 days (4-7 days). Morbidity was 57 % including one deep wound infection and a chronic sinus requiring reoperation. There were no hernia recurrences with average follow-up of 15 months (3-63 months).

CONCLUSIONS

Hybrid laparoscopic and open techniques may be used in obese patients with difficult incisional hernias requiring open adhesiolysis. Further studies need to be done to better delineate hernia characteristics of patients that may benefit from this approach.

Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction

Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007-2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

Evaluation of ultrasound for identification of abdominal wall myofascial components by novice learners

BACKGROUND

Minimally invasive components separation (MICS) is believed to decrease wound complications by reducing local tissue damage and eliminating the interruption of blood supply to the overlying skin and soft tissue. One drawback to the MICS technique is the difficulty with identifying the correct location for entry into the anterior abdominal wall. We believe that ultrasound can be used to visually assist identification of the correct surgical entry site (the avascular space between the external and internal abdominal oblique muscles, lateral to the linea semilunaris).

PURPOSE

The purpose of this study was to assess if novices can readily learn an ultrasound technique for identifying abdominal wall myofascial components via a video education tool.

METHODS

This research was an institutional review board-approved, prospective, observational study. Ten surgical residents were asked to watch a 1-min training video containing basic instructions on ultrasound technique for identifying the myofascial anatomy of the anterior abdominal wall. After watching the educational video, the subjects were asked to identify the linea semilunaris first by external anatomy, then by ultrasound. A grader, blinded to the identification of the subject, recorded if the subject correctly identified the location of the linea semilunaris by each method (external anatomy only versus ultrasound guided).

RESULTS

Ten subjects were evaluated. Nine of ten (90 %) subjects correctly identified the linea semilunaris with ultrasound. Only three of ten (30 %) subjects correctly identified the linea semilunaris by physical exam.

CONCLUSIONS

Ultrasound technology can aid in identification of the abdominal wall musculofascial units in MICS and be easily taught via short video instruction to novices with excellent results. Further studies will be necessary to prove that ultrasound use can decrease complications associated with entry into the appropriate avascular space between the external and internal abdominal oblique muscles, lateral to the linea semilunaris.

Options for closure of the infected abdomen

BACKGROUND

The infected abdomen poses substantial challenges to surgeons, and often, both temporary and definitive closure techniques are required. We reviewed the options available to close the abdominal wall defect encountered frequently during and after the management of complicated intra-abdominal infections.

METHODS

A comprehensive review was performed of the techniques and literature on abdominal closure in the setting of intra-abdominal infection.

RESULTS

Temporary abdominal closure options include the Wittmann Patch, Bogota bag, vacuum-assisted closure (VAC), the AbThera™ device, and synthetic or biologic mesh. Definitive reconstruction has been described with mesh, components separation, and autologous tissue transfer.

CONCLUSION

Reconstructing the infected abdomen, both temporarily and definitively, can be accomplished with various techniques, each of which is associated with unique advantages and disadvantages. Appropriate judgment is required to optimize surgical outcomes in these complex cases.

Biologic grafts for ventral hernia repair: a systematic review

BACKGROUND

Biologic grafts hold promise of a durable repair for ventral hernias with the potential for fewer complications than synthetic mesh. This systematic review was performed to evaluate the effectiveness and safety of biologic grafts for ventral hernia repair.

METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched for studies on biologic grafts for the repair of ventral hernias. Outcomes are presented as weighted pooled proportions.

RESULTS

Twenty-five retrospective studies were included. Recurrence depended on wound class, with an overall rate of 13.8% (95% confidence interval [CI], 7.6-21.3). The recurrence rate in contaminated/dirty repairs was 23.1% (95% CI, 11.3-37.6). Abdominal wall laxity occurred in 10.5% (95% CI, 3.7-20.3) of patients. The surgical morbidity rate was 46.3% (95% CI, 33.3-59.6). Infection occurred in 15.9% (95% CI, 9.8-23.2) of patients but only led to graft removal in 4.9% of cases.

CONCLUSIONS

No randomized trials are available to properly evaluate biologic grafts for ventral hernia repair. The current evidence suggests that biologic grafts perform similarly to other surgical options. Biologic grafts are associated with a high salvage rate when faced with infection.

Closure of midline contaminated and recurrent incisional hernias with components separation technique reinforced with plication of the rectus muscles

PURPOSE

Midline incisional hernia reconstruction by defect closure and reinforcement with either prosthetic or biologic materials has shown to significantly decrease recurrence rates even for complex cases. The purpose of this study is to evaluate outcomes regarding large incisional hernia reconstruction with components separation technique using rectus muscle plication as a reinforcement method.

METHODS

Thirteen patients having large midline incisional hernias and either history of abdominal wall contamination or recurrence in the presence of mesh were treated between January 2007 and December 2011 with closure using components separation technique reinforced by rectus muscle plication.

RESULTS

Average hernia square was 222 cm(2), and mean follow-up was 24 months. Complications occurred in 6 patients with a mean time to resolution of 59 days. One recurrence was present.

CONCLUSIONS

When use of mesh or biologic materials is not desired, rectus muscle plication is a feasible tool as a reinforcement method after large hernia closure with components separation.

Repair of incisional hernias with biological prosthesis: a systematic review of current evidence

BACKGROUND

No consensus has been reached on the use of bioprosthetics to repair abdominal wall defects. The purpose of this systematic review was to summarize the outcomes from studies describing this use of various bioprosthetics for incisional hernia repair.

METHODS

Studies published by October 2011 were identified through literature searches using EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials.

RESULTS

A total of 491 articles were scanned, 60 met eligibility criteria. Most studies were retrospective case studies. The studies ranged considerably in methodologic quality, with a modified Methodological Index of Nonrandomized Studies score from 5 to 12. Many repairs were performed in contaminated surgical sites (47.9%). At least one complication was seen in 87% of repairs. Major complications noted were wound infections (16.9%) and seroma (12.0%). With a mean follow-up period of 13.6 months the hernia recurrence rate was 15.2%.

CONCLUSIONS

There is an insufficient level of high-quality evidence in the literature on the value of bioprosthetics for incisional hernia repair. Randomized controlled trials that use standardized reporting comparing bioprosthetics with synthetic mesh for incisional hernia repair are needed.

Survey on Ventral Hernias: Surgeon Indications, Contraindications, and Management of Large Ventral Hernias

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons’ perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons’ perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: a prospective study

INTRODUCTION

The surgical treatment of large incisional hernias with loss of domain (LIHLD) carries the risk of fascia closure under tension and, thus, abdominal compartment syndrome. We investigated volume measurements as a predictive factor for tension-free fascia closure.

PATIENTS AND METHODS

From September 2004 to July 2008, we prospectively included 17 patients with LIHLD. The operation was prepared by a progressive preoperative pneumoperitoneum (PPP) technique known as the Goni Moreno procedure. The patient's age and body mass index (BMI), the incisional hernia's width, length and surface area, and the incisional hernia volume (IHV)/peritoneal volume (PV) ratio <20% were evaluated as predictive factors for tension-free fascia closure. A tension-free closure was defined as a closure in which the use of a surgical device for avoiding postoperative compartment syndrome was not required.

RESULTS

The mean PPP volume introduced was 12.7 ± 4.4 l (range 4.5-19.2) over a period of 11 ± 6 days (range 4-24). The mean width, height and surface area of the incisional hernia after PPP were 11.3 ± 4.7 cm (range 4.5-19), 13.4 ± 7.8 cm (range 4.4-30) and 165 ± 101 cm(2) (range 19-304), respectively. The mean IHV after PPP was 2,374 ± 1,356 cc (range 517-4,802) and the mean abdominal cavity volume was 9,558 ± 4,106 cc (range 4,785-21,782). The mean IHV/PV ratio was 16.3 ± 10.4% (range 4.4-34). In a univariate analysis, the BMI and the IHV/PV ratio were predictive of tension-free fascia closure. In a multivariate analysis, only an IHV/PV ratio <20% was a significant predictive factor.

CONCLUSIONS

The IHV/PV ratio is predictive of tension-free fascia closure for hernias or incisional hernias with loss of domain. Simplification of the volumetry method is necessary.

Preliminary experience and development of an algorithm for the optimal use of the laparoscopic component separation technique for myofascial advancement during ventral incisional hernia repair

BACKGROUND

Component separation technique (CST) enables rectus abdominus medialization, but may cause wound complications. Few published outcomes exist involving laparoscopic CST. Our aim was to examine feasibility and outcomes involving open and laparoscopic (lap) CST during ventral incisional hernia repair (VIHR) and present an algorithm for ventral herniorrhaphy.

STUDY DESIGN

Our design was a retrospective cohort study. Over 22 months, 28 patients underwent one of the following: (i) unilateral (U-) lap CST with open VIHR [n = 5], (ii) bilateral (B-) lap CST with open VIHR [n = 7], (iii) B-lap CST with lap VIHR [n = 8], or (iv) B-open CST with open VIHR [n = 8]. Indications for open VIHR included mesh removal, concomitant visceral procedure, wound revision, thin/ulcerated skin, abdominal wall tumor, frozen abdomen, and/or off-midline hernia. During open VIHR, CST was performed in the Ramirez fashion. Lap CST was performed before intraperitoneal access in lap VIHR and after retrorectus dissection in open VIHR. Patient surveillance consisted of clinical encounters and telephone interviews.

RESULTS

Groups were similar regarding age, body mass index, American Society of Anesthesiologists classification, hernia width, operative time, and hospital stay. Six of the 20 patients who underwent open VIHR developed wound complications, and two required early reoperation. Four of the six with concomitant visceral procedures had wound complications. No laparoscopic VIHR patients had a wound complication. Based on 11 months' follow-up, one open VIHR patient has concern for recurrence.

CONCLUSIONS

Laparoscopic CST is feasible during open and laparoscopic VIHR, but it appears most beneficial for wound healing after laparoscopic VIHR. During open VIHR, laparoscopic CST may not substantially reduce wound complications.

Comparison of three separate antiadhesive barriers for intraperitoneal onlay mesh hernia repair in an experimental model

Background

Adhesion formation is a common adverse effect in intraperitoneal onlay mesh (IPOM) surgery. Different methods of adhesion prevention have been developed, including coated meshes and separate antiadhesive barriers (SABs). In this study one type of mesh was tested with different SABs, which were fixed to the sutured mesh using fibrin sealant. The primary aim was to compare adhesion prevention between different SABs. Secondary aims were the assessment of tissue integration and evaluation of SAB fixation with fibrin sealant.

Methods

Thirty-two rats were randomized to one of three treatment groups (SurgiWrap®, Prevadh® and Seprafilm®) or a control group (no SAB). Animals were operated on with an open IPOM technique (8 per group). One macroporous polypropylene mesh per animal (2 × 2 cm) was fixed with four non-absorbable sutures. An antiadhesive barrier of 2·5 × 2·5 cm was fixed with fibrin sealant. After 30 days, adhesion formation, tissue integration, seroma formation, inflammation and vascularization were evaluated macroscopically and by histology.

Results

Prevadh® and Seprafilm® groups showed a significant reduction in adhesion formation compared with the control group. Tissue integration of the mesh was reduced in these groups. Fibrin sealant fixed the SAB to the mesh securely in all groups.

Conclusion

Prevadh® and Seprafilm® are potent materials for the reduction of adhesion formation. A potential relationship between effective adhesion prevention and impaired tissue integration of the implant was observed. Fibrin sealant proved an excellent agent for SAB fixation.

Abdominal wall infections with in situ mesh

BACKGROUND

Synthetic mesh is used commonly in the repair of abdominal wall hernias. Infection at the surgical site where mesh is present poses a formidable clinical problem.

METHODS

The current surgical literature was reviewed to formulate accepted approaches to the management of hernia repairs with infected mesh.

RESULTS

Prevention of mesh infection is best achieved by judicious use of systemic antibiotics. Topical antibiotics often are used without convincing evidence to support their value. Laparoscopic repairs have lower infection rates than open repairs. Evidence is lacking to support lower rates of infection with mesh of specific composition or with antibacterial agents that coat the mesh. The diagnosis of mesh infection is principally a clinical one. Repairs of infected mesh usually necessitate antibiotics and removal of the foreign material. Clinical judgment is required for attempts at salvaging portions of the mesh. Component separation or biological materials may be used in those circumstances for hernia repair in which large defects are created by removal of the infected synthetic material.

CONCLUSIONS

Prevention of mesh infections remains the best strategy. Clinical judgment is essential in determining the degree of mesh removal. Continued clinical studies are necessary to improve the outcomes of established mesh infection in hernia repairs.

Modified onlay technique for the repair of the more complicated incisional hernias: single-centre evaluation of a large cohort

Background

The repair of incisional hernias remains a challenge for the general surgeon. Indications for surgery are severe bowel obstruction, as well as aesthetic problems. There are various surgical methods to correct these hernias, with varying results. However, the gold standard has not yet been found. Both laparoscopic repair and the component separation technique (CTS) have proven to be acceptable techniques; however, they are not always suitable for resolving the more complicated abdominal wall defects, i.e. after open-abdomen treatment or fascial necrosis. In our hospital, we developed a new onlay technique which we have evaluated in the following research.

Patients and methods

During a period of 10 years (1996–2007), 101 patients with an incisional hernia were corrected with the new onlay technique. A Marlex mesh of dimensions at least 10 × 20 cm was used, overlapping the fascia by at least 5 cm on each side. This mesh was stapled onto the fascia with skin staples. Of the 101 patients, there were 45 men and 56 women, with a mean age of 55 years. Nine patients died and 13 were lost during follow-up. Of the remaining 79 patients, eight refused to participate. The mean follow-up time was 64 months (normal distribution, standard deviation [SD] 34 months). This cohort of 101 patients was studied retrospectively.

Results

Seventy-one of the 101 patients were evaluated at our out-patient clinic. For 24 patients (25%), the operation was for a recurrence after an incisional hernia correction in the past. Twenty-one patients (20%) had an open-abdomen treatment in their medical history. The surgical procedure was technically possible in all patients and the mean operation time was 63 min. The median admission time was 4.5 days (quartiles 3–6.25). The mean follow-up time was 64 months (SD 35 months). A seroma was reported in 27 of 101 patients (27%) and a wound infection in 22 patients (21%), of which seven patients had to be re-operated. Only if a patient was evaluated at our out-patient clinic could reherniation have been scored; this occurred in 11 of 71 patients (16%).

Conclusion

This technique is an effective and simple procedure to correct incisional hernias with acceptable complication rates and is feasible even in the more complicated hernias.

Early Results of Midline Hernia Repair Using a Minimally Invasive Component Separation Technique

A minimally invasive component separation may lead to a dynamic abdominal wall after hernia repair, with reduced complications. We present early results of our patients undergoing this technique. Five patients were selected for open midline repairs; three with chronic infections, one with a prior midline skin graft, and one who desired a primary, tension-free repair. These three males and two females had a mean age of 50.8 ± 21.1 years and body mass index of 30.9 ± 6.2. The mean number of previous abdominal operations was 7 ± 3.4 and previous attempted hernia repairs were 4 ± 2.7. All patients had a midline laparotomy with lysis of adhesions. An endoscopic component separation was then performed bilaterally. Drains were left in the dissection bed. All patients had the midline closed; four received biologic mesh underlays. Mean operative time was 227 minutes ± 49. Mean length of stay (LOS) was 9.2 days ± 3.6. Early median follow-up was 6 months (range 0.25–9). Two patients required postop transfusions, and two patients had mild complications of the midline wound (hematoma, infection). To date, one recurrence was diagnosed by CT scan. Early evaluation of adopting the minimally invasive (MIS) component separation demonstrates minimal complications and good initial outcomes.