Systematic review and meta-analysis of the repair of potentially contaminated and contaminated abdominal wall defects

Synthetic vs. biologic mesh for abdominal wall reconstruction in contaminated surgical fields. A meta-analysis of randomized controlled trials and observational studies

PURPOSE

Biologic meshes had been the first choice for abdominal wall reconstruction (AWR) in contaminated surgical fields. However, due to increased cost and questioned effectiveness, synthetic meshes have been also implemented. The aim of the present meta-analysis was to compare synthetic and biologic mesh in terms of recurrence and postoperative outcomes.

METHODS

The present meta-analysis was designed using the PRISMA guidelines. A search in Medline, Scopus, EMBASE, Clinicaltrials.gov, Google Scholar and Cochrane CENTRAL was conducted from inception until September 2024. Randomized clinical trials (RCTs) and observational studies which compared the use of biologic and synthetic mesh for AWR in contaminated surgical fields were included. Data were extracted by two experienced researchers in pre-defined electronic forms. Pooled odds ratios (OR) and mean differences (MD) were calculated using a random-effects model. Included RCTs were assessed using the Risk of Bias 2 (RoB2) tool and non-randomized trials with the Risk of Bias in non-Randomized Trials (RoBINS-I) tool.

RESULTS

Overall 11 studies were included which enrolled 1,945 patients. Subgroup analysis of RCTs indicated significantly lower recurrence rates for synthetic compared to biologic mesh (p < 0.0001) with a similar follow-up (p = 0.07). Nevertheless, no difference was demonstrated in surgical site infection (SSI) rates. Although synthetic mesh was associated with shorter length of stay, the other postoperative outcomes (surgical site occurrences, mesh infections, readmissions, reoperations) were similar among the two groups.

CONCLUSION

Synthetic mesh should be considered as a safe and effective option for abdominal wall reconstruction in contaminated surgical fields compared to biologic mesh. Nevertheless, future research is expected to investigate cost-effectiveness of biosynthetic meshes, as alternative option in such surgical fields.

The Great Debate: Mesh or No Mesh in Contaminated Hernia Repairs?

Abdominal hernia surgeries are commonly performed with many different approaches, and mesh utilization has become a cornerstone in hernia repair, ensuring durable outcomes with minimal recurrence risk. However, managing contaminated hernia repairs presents unique challenges due to the heightened risks of mesh infection. Recent advancements in lightweight macroporous polypropylene meshes offer promising solutions. Studies have highlighted the superiority of macroporous polypropylene meshes compared to primary suture repair and other mesh types in terms of reduced surgical site infection rates and lower hernia recurrence rates. Moreover, utilizing macroporous polypropylene mesh in the retrorectus plane is associated with a favorable salvage rate, underscoring its efficacy in contaminated hernia repairs. At the same time, contrary evidence suggests higher postoperative complications with mesh use in settings of clean-contaminated or contaminated fields. Most significant complications are increased infection rates and similar recurrence rates compared to mesh-free repairs. New synthetic mesh that is being marketed as having better outcomes than other types of mesh and potentially primary repair need to be carefully assessed as biologic mesh once used to also be touted as the mesh to use in such fields, but more research is showing higher complication rates. The risk of infection and consequent morbidity might outweigh the benefit of less recurrence risk with mesh use. Further research, including prospective studies with long-term follow-up, is warranted to elucidate optimal hernia repair strategies in contaminated fields and inform evidence-based practice guidelines.

Long-term results with biosynthetic absorbable P4HB mesh in ventral abdominal wall repair: a multicentre analysis

BACKGROUND

The aim of this multicentre study was to analyse the outcomes of biosynthetic absorbable poly-4-hydroxybutyrate (P4HB) prosthesis implantation in patients undergoing ventral hernia repair (VHR) in the context of different degrees of contamination.

METHODS

From May 2016 to December 2021, a multicentre retrospective analysis of patients who underwent elective or urgent hernia repair with P4HB prosthesis was performed in seven hospitals in Spain and Portugal. Patients with a postoperative follow-up of less than 20 months and those within the theoretical period of prosthesis resorption were excluded from the study. Regarding the degree of contamination, patients were assessed according to the modified Ventral Hernia Working Group (VHWG) classification. Epidemiological data, hernia characteristics, surgical and postoperative variables (Clavien-Dindo classification) of these patients were analyzed. Risk factors related to long-term recurrence were studied by a multivariate analysis.

RESULTS

In 236 cases of P4HB prosthesis implantation, repair in cases of Grade 3 was the most frequent (49.1%), followed by Grade 2 in 42.3% of cases and Grade 1 in 8.4%. The most frequent complications were Grade 1, with the majority occurring during the first year. The overall rate of surgical site occurrences (SSO) was 30%. The hernia recurrence rate was 14.4% (n = 34), with a mean postoperative follow-up time of 41 months (22-61). The multivariate analysis showed that the onlay location of the mesh (OR 1.07; CI 1.42-2.70, p = 0.004) was a significant independent risk factor for recurrence.

CONCLUSIONS

The use of a P4HB bioresorbable mesh for the VHR with different degrees of contamination leads to favourable results overall, with an acceptable rate of hernia recurrence. The onlay location of the P4HB prosthesis is the main factor in recurrence in both elective and emergency settings.

Synthetic Versus Biological Mesh in Ventral Hernia Repair and Abdominal Wall Reconstruction: A Systematic Review and Recommendations from Evidence-Based Medicine

AIM

To compare the efficacy and safety of synthetic and biological meshes in ventral hernia repair (VHR) and abdominal wall reconstruction (AWR).

METHODS

We screened all clinical trials that reported the application of synthetic and biological meshes in VHR and AWR using Medline, Web of Science, and Embase (Ovid). Only comparative studies with similar baselines such as age, sex, body mass index, degree of wound contamination, and hernia defects between the intervention and control groups were included. Effect sizes with 95% confidence were pooled using a random- or fixed-effects model based on the size of heterogeneity. A sensitivity analysis was performed to test the stability of the results.

RESULTS

Ten studies with 1305 participants were included. Biological meshes were associated with significantly higher recurrence rate (OR, 2.09; 95% CI 1.42-3.08; I2 = 50%), surgical site infection (OR, 1.47; 95% CI 1.10-1.97; I2 = 30%), higher re-admission rate (OR, 1.51; 95% CI 1.05-2.17; I2 = 50%), and longer length of hospital stay (SMD, 0.37; 95% CI 0.10-0.65; I2 = 72%). Similar surgical site occurrence, re-operation rate, and mesh explantation rate were observed among biological and synthetic meshes. Biological meshes have no difference in recurrence rate as compared to synthetic meshes, between the clean-contaminated, and contamination-infected fields (OR, 1.41; 95% CI 0.41-4.87 vs 3.00; 95% CI 1.07-8.46; P = 0.36).

CONCLUSION

Synthetic meshes are a safe alternative to biological meshes for VHR and AWR. Considering the high cost of biological meshes, synthetic meshes are more appropriate for the VHR and AWR.

Bubble plastic use in rats hernioplasty: Uso do plástico bolha em hernioplastias de ratos

Purpose

Despite the high frequency of hernioplasties worldwide, their complications and recurrences are still a challenge to be overcome. The search for prostheses that aim to promote the correction of hernia defects has been a challenge. For this purpose, the materials used in hernioplasties must be biocompatible, promote the formation of little or no peritoneal adhesion, possess compatible texture and flexibility, providing the necessary resistance to protect the viscera and allow the movement of the abdomen.

Methods

The aim of the present study was to evaluate the effectiveness of bubble plastic (low density polyethylene, LDPE) as a material for the correction of hernia in the abdominal wall. For this, twenty male rats (Rattus norvegicus, Wistar variety) were used and divided into four groups of five animals. The animals were evaluated at 7, 15, 30 and 90 days after surgery according to clinical, thermographic and morphological parameters (macroscopic and microscopic).

Results

The results showed that the bubble plastic induced inflammatory reaction in the initial period (7 day), followed by a reduction (30 day) to increase considerably at 90 days after the operation.

Conclusion

So, bubble plastic can be used for temporary implants (up to 30 days).

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study

BACKGROUND

Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study.

METHODS

A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated.

RESULTS

Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm² vs botulinum toxin A 289.7 ± 162.4 cm²; P = .73) (mean volume: 1,498.3 + 2,043.4 cm³ vs 2,914.7 + 6,539.4 cm³; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13).

CONCLUSION

In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

Permanent vs Absorbable Mesh for Ventral Hernia Repair in Contaminated Fields: Multicenter Propensity-Matched Analysis of 1-Year Outcomes Using the Abdominal Core Health Quality Collaborative Database

BACKGROUND

Traditionally, the use of absorbable mesh in contaminated fields aimed to reduce postoperative morbidity at the expense of increased hernia recurrence. This dogma has recently been challenged in randomized trials that demonstrate the advantages of permanent mesh in this setting. Although these studies are of high quality, their reproducibility across institutions is limited. We sought to compare the outcomes between permanent and absorbable mesh in a multicentric cohort from the Abdominal Core Health Quality Collaborative.

STUDY DESIGN

Patients who underwent elective ventral hernia repair in class II and III surgeries from January 2013 to December 2021 were identified within the Abdominal Core Health Quality Collaborative. Outcomes were compared among permanent (P), absorbable synthetic (AS), and biologic (B) mesh at 30 days and 1 year using a propensity score-matched analysis.

RESULTS

A total of 2,484 patients were included: 73.4% P, 11.2% AS, and 15.4% B. Of these, 64% were clean-contaminated and 36% contaminated interventions. After propensity score-matched analysis, there was no significant difference between groups regarding surgical site occurrence (P 16%, AS 15%, B 21%, p = 0.13), surgical site infection (P 12%, AS 14%, B 12%, p = 0.64), and surgical site occurrence requiring procedural intervention at 30 days (P 12%, AS 15%, B 17%, p = 0.1). At 1 year, the recurrence rate was significantly lower among the permanent group (P 23%, AS 40%, B 32%, p = 0.029).

CONCLUSIONS

In this multicentric cohort, permanent mesh has equivalent 30-day outcomes and lower rates of hernia recurrence at 1 year after hernia repair in contaminated fields.

Ventral hernia repair in high-risk patients and contaminated fields using a single mesh: proportional meta-analysis

PURPOSE

The use of mesh is a common practice in ventral hernia repair (VHR). Lack of consensus on which prosthetic material works better in different settings remains. This meta-analysis aims to summarize the available evidence on hernia recurrence and complications after repair with synthetic, biologic, or biosynthetic/bioabsorbable meshes in hernias grade 2-3 of the Ventral Hernia Working Group modified classification.

METHODS

A literature search was conducted in January 2021 using Web of Science (WoS), Scopus, and MEDLINE (via PubMed) databases. Randomized Controlled Trials (RCTs) and observational studies with adult patients undergoing VHR with either synthetic, biologic, or biosynthetic/bioabsorbable mesh were included. Outcomes were hernia recurrence, Surgical Site Occurrence (SSO), Surgical Site Infection (SSI), 30 days re-intervention, and infected mesh removal. Random-effects meta-analyses of pooled proportions were performed. Quality of the studies was assessed, and heterogeneity was explored through sensitivity analyses.

RESULTS

25 articles were eligible for inclusion. Mean age ranged from 47 to 64 years and participants' follow-up ranged from 1 to 36 months. Biosynthetic/bioabsorbable mesh reported a 9% (95% CI 2-19%) rate of hernia recurrence, lower than synthetic and biologic meshes. Biosynthetic/bioabsorbable mesh repair also showed a lower incidence of SSI, with a 14% (95% CI 6-24%) rate, and there was no evidence of infected mesh removal. Rates of seroma were similar for the different materials.

CONCLUSIONS

This meta-analysis did not show meaningful differences among materials. However, the best proportions towards lower recurrence and complication rates after grade 2-3 VHR were after using biosynthetic/slowly absorbable mesh reinforcement. These results should be taken with caution, as head-to-head comparative studies between biosynthetic and synthetic/biologic meshes are lacking. Although, biosynthetic/bioabsorbable materials could be considered an alternative to synthetic and biologic mesh reinforcement in these settings.

A Trilayer Dressing with Self-Pumping and pH Monitoring Properties for Promoting Abdominal Wall Defect Repair

Due to abdominal infection, excessive wound exudation, and intestinal fistula formation, the treatment of full-thickness abdominal wall defects has become a difficult challenge for clinic doctors. This clinical problem cannot be resolved with existing biomaterials. To facilitate the repair of the abdominal wall, we developed a novel wound dressing with directional biofluid transport. We used electrospinning to spin a trilayer dressing consisting of hydrolyzed poly-acrylonitrile (HPAN)/Curcumin (CUR), polyurethane (PU), and polycaprolactone (PCL). In vitro results show that the three-layer wound dressing is biocompatible, capable of directional transport of excessive wound exudation, preventing reverse penetration, and monitoring the pH of the wound. Furthermore, in vivo results show the trilayer wound dressing improves the wound microenvironment, reduces inflammatory factors, promotes angiogenesis, and accelerates abdominal wall repair. Thus, we believe that the novel trilayer electrospinning dressing could facilitate abdominal wall defect repair.

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.

"Delayed-Immediate" Hernia Repairs in Infected Wounds: Clinical and Economic Outcomes

BACKGROUND

Wound class in hernia repairs impacts surgical technique and outcomes. Hernia recurrence and complications are high when dirty wounds are treated in one stage. We hypothesize patients who undergo intentionally staged repairs are less likely to have adverse outcomes and associated costs.

METHODS

Patients were identified by retrospective chart review. Patient characteristics and outcome variables were collected. An economic analysis of cost variables was performed using medical records and published meta-analyses.

RESULTS

There were 8 patients in the staged repairs group and 10 patients in the control group. Length of stay was 14.9 days (±8.8), and 8.7 days (±6.4), respectively. Rate of hernia recurrence within 1 year was 14.3% and 37.5%. Rate of mesh infection at 30 days was 0% and 10%. Compared to controls, delayed-immediate repairs had a nearly 2-fold index surgical cost.

DISCUSSION

Although there is an increased cost associated with delayed-immediate repairs, this cost may be offset by the decreased infection, seroma, dehiscence, enterocutaneous fistula formation, and hernia recurrence rate that necessitates future interventions. Further data collection is required to determine if clinical and economic benefit is seen long-term.

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.

VERSATILITY OF POLY-4-HYDROXYBUTYRATE (PHASIX™) MESH IN ABDOMINAL WALL SURGERY

BACKGROUND

Poly-4-hydroxybutyrate (P4HB) is a naturally occurring polymer derived from transgenic E. coli bacteria with the longest degradation rate when compared to other available products. This polymer has been manufactured as a biosynthetic mesh to be used as reinforcement when repairing a variety of abdominal wall defects.

OBJECTIVE

We aim to describe our center initial experience with this mesh and discuss the possible indications that may benefit from the use of P4HB mesh.

METHODS

This is a descriptive retrospective study of patients who underwent abdominal wall repair with a P4HB mesh from October 2018 to December 2020 in a single, large volume, academic center.

RESULTS

A total of 51 patients (mean age 54.4 years, range 12-89) underwent abdominal wall reconstruction with a P4HB mesh between October 2018 and December 2020. The mean BMI was 30.5 (range 17.2-50.6). Twenty-three (45%) patients had a prior hernia repair at the site. We grouped patients into six different indications for the use of P4HB mesh in our cohort: clean-contaminated, contaminated or infected field (57%), patient refusal for permanent meshes (14%), those with high risk for post-operative infection (12%), visceral protection of second mesh (10%), recurrence with related chronic pain from mesh (6%), and children (2%). Median follow-up was 105 days (range 8-648). Two patients had hernia recurrence (4%) and 8 (16%) patients developed seroma.

CONCLUSION

P4HB mesh is a safe and a viable alternative for complex hernias and high-risk patients with a low complication rate in the short-term.

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.

Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.

An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis

AIMS

To evaluate comparative outcomes of emergency laparotomy closure with and without prophylactic mesh.

METHODS

A systematic review was performed via literature databases: PubMed, Cochrane Library, Science Direct, and Google Scholar. Studies were examined for eligibility and included if they compared prophylactic mesh closure to the conventional laparotomy closure following emergency abdominal surgery. Both acute wound failure and incisional hernia (IH) occurence were our primary outcomes. Secondary outcomes included surgical site infection (SSI), seroma/hematoma formation, Clavien-Dindo complications (score ≥ 3), total operative time, and length of hospital stay (LOS).

RESULTS

Two randomised controlled trials (RCTs) and four comparative studies with a total of 817 patients met the inclusion criteria. Overall acute wound failure and incisional hernia rate was significantly lower in the mesh group compared to non-mesh group (odd ratio (OR) 0.23, p = 0.002) and (OR 0.21, p = 0.00001), respectively. There was no significant difference between the two groups regarding the following outcomes: total operative time (mean difference (MD) 21.44, p = 0.15), SSI (OR 1.47, p = 0.06), seroma/haematoma formation (OR 2.74, p = 0.07), grade ≥ 3 Clavien-Dindo complications (OR 2.39, p = 0.28), and LOS (MD 0.26, p = 0.84).

CONCLUSION

The current evidence for the use of prophylactic mesh in emergency laparotomy is diverse and obscure. Although the data trends towards a reduction in the incidence of IH, a reliable conclusion requires further high-quality RCTs to fully assess the efficacy and safety of mesh use in an emergency setting.

Outcomes of posterior component separation with transversus abdominis release (TAR) in large and other complex ventral hernias: a single-surgeon experience

PURPOSE

Over the last years, great advances in the repair of abdominal wall hernias have dramatically improved patients' outcomes. Especially for large and other complex ventral hernias, the application of component separation techniques has been a landmark in their successful management. The aim of this study is to present our experience with the posterior component separation with transversus abdominis release (TAR) in patients with these demanding ventral hernias.

METHODS

A retrospective analysis of prospectively collected data of all patients who underwent elective ventral hernia repair with TAR between January 2016 and December 2019 was performed. Preoperative, intraoperative, and postoperative data were analyzed.

RESULTS

A total of 125 patients with large and other complex ventral hernias were included in the final analysis. More than 80% of patients had one or more comorbidities. Of all patients, 116 (92.8%) had a history of previous abdominal surgery, 27 (21.6%) had a history of SSI and nine (7.2%) had active fistulas. Postoperatively, SSOs were presented in 11 patients (8.8%), including three cases of SSI. Neither mesh infection occurred, nor mesh excision required. With a mean follow-up of 2.5 years, only one recurrence was observed.

CONCLUSIONS

With a wound complication rate of less than 9% and a recurrence rate of less than 1%, our results show that TAR is a reliable, safe and effective technique for the repair of massive and other complex ventral hernias. The combination of knowledge of the abdominal wall anatomy at a proficient level, proper training, and adoption of a strict prehabilitation program are considered prerequisites for the successful management of such demanding hernias.

Interposition of a biological mesh may not affect the rate of rectovaginal fistula after excision of large rectovaginal endometriotic nodules: a pilot study of 209 patients

AIM

The aim of this work was to assess whether placement of a biological mesh (Permacol^® ) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis.

METHOD

We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3 cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups.

RESULTS

Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety-two per cent of cases and 86.2% of controls had rectal infiltration more than 3 cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4 ± 1.4 cm vs. 6 ± 2.9 cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3-9.5). A distance of less than 7 cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7-132).

CONCLUSION

Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

Feasibility study of oxidized hyaluronic acid cross-linking acellular bovine pericardium with potential application for abdominal wall repair

Bovine pericardium(BP)is one of the biological membranes with extensive application in tissue engineering. To fully investigate the potential clinical applications of this natural biological material, a suitable cross-linking reagent is hopefully adopted for modification. Glutaraldehyde (GA) is a clinically most common synthetic cross-linking reagent. In the study, oxidized hyaluronic acid (AHA) was developed to substitute GA to fix acellular bovine pericardium (ABP) for lower cytotoxicity, aiming to evaluate the feasibility of AHA as a cross-linking reagent and develop AHA-fixed ABP as a biological patch for abdominal wall repair. The AHA with the feeding ratio (1.8:1.0) has an appropriate molecular weight and oxidation degree, almost no cytotoxicity and good cross-linking effect. The critical cross-linking characteristics and cytocompatibility of AHA-fixed ABP were also investigated. The results demonstrated that 2.0% AHA-fixed ABP had the most suitable mechanical properties, thermal stability, resistance to enzymatic degradation and hydrophilicity. Moreover, 2.0% AHA-fixed samples exhibited an excellent cytocompatibility with human peritoneal mesothelial cells (HPMC) and low antigenicity. It also showed a prominent anti-calcification ability required for abdominal wall repair. Our data provided experimental basis for future research on AHA as a new cross-linking reagent and AHA-fixed ABP for abdominal wall repair.

Outcomes of mid-term and long-term degradable biosynthetic meshes in single-stage open complex abdominal wall reconstruction

OBJECTIVE

To assess clinical outcomes in patients that underwent open single-stage complex abdominal wall reconstruction (CAWR) with biosynthetic mesh.

METHODS

Retrospective observational study of two prospectively registered series of consecutive patients undergoing CAWR with either long-term degradable (LTD) Phasix^™ or mid-term degradable (MTD) BIO-A^® biosynthetic mesh in a single institution between June 2016 and December 2019.

RESULTS

From 169 patients with CAWR, 70 consecutive patients were identified who underwent CAWR with either LTD or MTD biosynthetic mesh. More than 85% of patients had an incisional hernia that could be classified as moderately complex to major complex due to a previous wound infection (67%), one or more complicating comorbidities (87.1%), one or more complicating hernia characteristics (75.7%) or contaminated or dirty defects (37.1%). Concomitant component separation was performed in 43 of 70 patients (61.4%). Overall surgical site infection (SSI) rate in these CAWR patients was 45.7%. Seventeen of 70 patients (24.3%) had computed tomography (CT) - and culture-confirmed SSI in direct contact of mesh, suspicious of mesh infection. Mesh removal for persistent local infection occurred in 10% (7 of 70) after a median of 229 days since surgery. Salvage rate of mesh after direct contact with infection was 58.8%. All removed meshes were in the LTD group. Seven patients (10%) had a recurrence; four patients in the LTD group (10%) had a recurrence at a median follow-up of 35 months and three patients in the MTD group (10%) at a median follow-up of 11 months. Three of the seven recurrences occurred in patients with SSI in persistent and direct contact with mesh.

CONCLUSIONS

Comorbid patients undergoing open complex abdominal wall reconstruction are at high risk of postoperative wound complications regardless of which type of biosynthetic mesh is used. When in persistent and direct contact with infection, long-term biodegradable biosynthetic meshes may need to be removed, whereas mid-term biodegradable biosynthetic meshes can be salvaged.

Reconstruction of Complex Abdominal Wall Defect With Autogenous Pedicled Demucosalized Seromuscular Flap

Abdominal wall reconstruction is indicated when 1 or more of the abdominal wall components (skin, fascia, or muscle) are either injured or absent. When faced with defects requiring flap reconstruction, the decision regarding flap choice should take into consideration the volume of soft tissue required, the extent of the defect, donor site morbidity, and prior surgical scars that affect flap vascularity. We present a case of an abdominal wall defect with limited reconstructive options in which a spare ileal bowel segment was filleted to create a seromuscular flap for improving the abdominal wall blood supply. The postoperative course was complicated by abdominal fluid collection, which resolved following an ultrasound-guided drain. The patient had normal wound healing and recovery without further postoperative complications at the 7-month follow-up. Seromuscular flaps are a practical option in the armamentarium of plastic surgeons performing abdominal wall reconstruction, especially when other alternatives are limited.

The use of Permacol® biological mesh for complex abdominal wall repair

BACKGROUND

Complex abdominal wall repair (CAWR) remains challenging, especially in contaminated fields where the use of a synthetic mesh is associated with prohibitively complication rates. Consequently, biological mesh has been proposed as an alternative. The aim of our study was to evaluate the safety and efficacy of using Permacol® in patients who had CAWR.

METHODS

We retrospectively reviewed the files of patients who had CAWR using the Permacol® mesh. Analysis included patients' preoperative characteristics, procedural parameters, and early and late post-operative complications including mainly recurrence. A multivariate regression model was performed to determine factors that influence 24-months recurrence rate.

RESULTS

Between January 2009 and December 2018, 75 patients. The most common indication was hernia in a contaminated field (48.0%) and abdominal wall defect greater than 10 cm in diameter (36%). Overall, 44% of our patients were Centers for Disease Control (CDC) class II or III and 81.3% fall into category II or III according to the Ventral Hernia Working Group (VHWG) classification. Recurrence rate of our series was 9.3%. Complete fascial closure was achieved in 60 patients (80%). Upon univariate analysis complete fascial closure, posterior component separation, seroma drainage, BMI >30 kg/m2 and age >65 years, VHWD grade >2, DINDO CLAVIEN class > 2 affected the recurrence rate at 2 years follow up. When subcutaneous drains are placed prophylactically, recurrence rates drop from 38.7% (5/14) to 3.3% (2/61 patients) when drains are placed at the time of operation (p=0.02). Only fascial closure affected the 24-months recurrence rate on multivariate analysis (p<0.001).

CONCLUSIONS

Permacol® surgical implant use for CAWR is safe with a relatively low rate of hernia recurrence at 2 years. Prophylactic subcutaneous drain placement may reduce the risk of hernia recurrence. The presence of contaminated fields does not appear to influence hernia recurrence when Permacol® is used, in fact, the only factor that affects recurrence rate at 24-months on multivariate analysis is completeness of the fascial closure.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes

BACKGROUND

While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB).

METHODS

Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed.

RESULTS

A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m². Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05).

CONCLUSION

For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Preventing Recurrence in Clean and Contaminated Hernias Using Biologic Versus Synthetic Mesh in Ventral Hernia Repair: The PRICE Randomized Clinical Trial

OBJECTIVE

The aim of this study was to evaluate which mesh type yields lower recurrence and complication rates after ventral hernia repair.

SUMMARY BACKGROUND DATA

More than 400,000 ventral hernia repairs are performed annually in the United States. Although the most effective method for repairing ventral hernias involves using mesh, whether to use biologic mesh versus synthetic mesh is controversial.

METHODS

Single-blind, randomized, controlled, pragmatic clinical trial conducted from March 2014 through October 2018; 165 patients enrolled with an average follow up of 26 months. Patients were randomized 1:1 to have their ventral hernias repaired using either a biologic (porcine) or synthetic (polypropylene) mesh. The primary study outcome measure was hernia recurrence at 2 years.

RESULTS

A total of 165 patients (68 men), mean age 55 years, were included in the study with a mean follow-up of 26 months. An intention-to-treat analysis noted that hernias recurred in 25 patients (39.7%) assigned to biologic mesh and in 14 patients (21.9%) assigned to synthetic mesh (P = 0.035) at 2 years. Subgroup analysis identified an increased rate of hernia recurrence in the biologic versus the synthetic mesh group under contaminated wound conditions (50.0% vs 5.9%; P for interaction = 0.041). Postoperative complication rates were similar for the 2 mesh types.

CONCLUSIONS

The risk of hernia recurrence was significantly higher for patients undergoing ventral hernia repair with biologic mesh compared to synthetic mesh, with similar rates of postoperative complications. These data indicate that the use of synthetic mesh over biologic mesh to repair ventral hernias is effective and can be endorsed, including under contaminated wound conditions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02041494.

Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis

Purpose

To evaluate safety and efficacy of a mesh reinforcement following stoma reversal to prevent stoma site incisional hernia (SSIH) and differences across the prostheses used.

Methods

A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Cochrane databases was conducted to identify comparative studies until September 2020. A meta-analysis of postoperative outcomes and a network meta-analysis for a multiple comparison of the prostheses with each other were performed.

Results

Seven studies were included in the analysis (78.4% ileostomy and 21.6% colostomy) with a total of 1716 patients with (n = 684) or without (n = 1032) mesh. Mesh placement was associated with lower risk of SSIH (7.8%vs18.1%, OR0.266,95% CI 0.123–0.577, p < 0.001) than no mesh procedures but also with a longer operative time (SMD 0.941, 95% CI 0.462–1.421, p < 0.001). There was no statistically significant difference in terms of Surgical Site infection (11.5% vs 11.1%, OR 1.074, 95% CI 0.78–1.48, p = 0.66), seroma formation (4.4% vs 7.1%, OR 1.052, 95% CI 0.64–1.73, p = 0.84), anastomotic leakage (3.7% vs 2.7%, OR 1.598, 95% CI 0.846–3.019, p = 0.149) and length of stay (SMD − 0.579,95% CI − 1.261 to 0.102, p = 0.096) between mesh and no mesh groups. Use of prosthesis was associated with a significant lower need for a reoperation than no mesh group (8.1% vs 12.1%, OR 0.332, 95% CI 0.119–0.930, p = 0.036). Incidence of seroma is lower with biologic than polypropylene meshes but they showed a trend towards poor results compared with polypropylene or biosynthetic meshes.

Conclusion

Despite longer operative time, mesh prophylactic reinforcement at the site of stoma seems a safe and effective procedure with lower incidence of SSIH, need for reoperation and comparable short-term outcomes than standard closure technique. A significant superiority of a specific mesh type was not identified.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02393-w.

Biologic mesh implantation is associated with serious abdominal wall complications in patients undergoing emergency abdominal surgery: A randomized-controlled clinical trial

BACKGROUND

Open, emergency abdominal surgery is associated with a high incidence of fascial dehiscence and incisional hernia. Implantation of biologic meshes potentially reinforces the abdominal wall and therefore decreases such complications. The aim of this prospective randomized study was to compare the outcome after prophylactic intraperitoneal implantation of a biologic Strattice mesh (Allergan, Dublin, Ireland) with standard abdominal closure in patients undergoing emergency abdominal surgery.

METHODS

A two-arm randomized clinical trial was performed in patients undergoing emergency abdominal surgery at Bern University Hospital, University of Bern, Switzerland, from April 2016 to March 2019. Patients were randomly assigned to prophylactic implantation of a biological intraperitoneal mesh using Strattice, Allergan (mesh group), or standard abdominal closure using a single, continuous running suture (no-mesh group). Because of safety concerns, patient enrollment was closed prematurely.

RESULTS

Eligibility for inclusion was assessed in 61 patients. A total of 48 patients were randomized (21 in the mesh group, 28 in the no-mesh group). No differences in baseline characteristics were found. Abdominal wall complications requiring reoperations were more frequent in the mesh group compared to the no-mesh group (5 [83.3%] of 13 vs. 1 [14.3%] of 13 patients, p = 0.026). Mesh-associated abdominal wall complications included nonintegration of the mesh into the abdominal wall, dissolution of the mesh, and mesh-related infections.

CONCLUSION

In patients undergoing emergency abdominal surgery, intraperitoneal biologic Strattice mesh implantation is associated with significantly more frequent abdominal wall complications requiring reoperation. Therefore, the use of such meshes cannot be recommended in the contaminated environment of emergency abdominal surgery.

LEVEL OF EVIDENCE

Therapeutic, level I.

Surgical site infection in mesh repair for ventral hernia in contaminated field: A systematic review and meta-analysis

BACKGROUND

Given the risk of surgical site infection (SSI), the use of mesh in contaminated ventral hernia repair (VHR) is not standardized and still a clinical dilemma. This meta-analysis aimed to assess whether mesh use increased the risk of SSI in patients following VHR in contaminated field.

METHODS

We performed a systematic review of published literature. Studies comparing the mesh repair and anatomic repair, the use of mesh in different Center for Disease Control and Prevention (CDC) wound classes and mesh repair with synthetic mesh or other type of meshes to treat complicated and contaminated VHR were considered for analysis. The main outcome was SSI incidence.

RESULTS

Six studies compared mesh and suture repairs. No significant difference in SSI incidence was observed between patients with complicated VHR in the mesh and suture repair groups.Five studies analyzed mesh repair in patients by field contamination level. There was no significant difference between the use of mesh in clean-contaminated, contaminated and dirty field versus clean wound class. Moreover, there was no significant difference between the use of mesh in clean-contaminated and contaminated cases.Four studies compared mesh repair technique with synthetic mesh or other type of meshes were included. The incidence of SSI was significantly lower in the synthetic mesh group.

CONCLUSIONS

The use of mesh repair in the management of complicated VHR compared to suture repair is not associated with an increased incidence of SSI even in potentially contaminated fields.

A structured pathway for developing your complex abdominal hernia service: our York pathway

PURPOSE

Clinical pathways are widely prevalent in health care and may be associated with increased clinical efficacy, improved patient care, streamlining of services, while providing clarity on patient management. Such pathways are well established in several branches of healthcare services but, to the authors' knowledge, not in complex abdominal wall reconstruction (CAWR). A stepwise, structured and comprehensive approach to managing complex abdominal wall hernia (CAWH) patients, which has been successfully implemented in our practice, is presented.

METHODS

A literature search of common databases including Embase® and MEDLINE® for CAWH pathways identified no comprehensive pathway. We therefore undertook a reiterative process to develop the York Abdominal Wall Unit (YAWU) through examination of current evidence and logic to produce a pragmatic redesign of our own pathway. Having introduced our pathway, we then performed a retrospective analysis of the complexity and number of abdominal wall cases performed in our trust over time.

RESULTS

We describe our pathway and demonstrate that the percentage of cases and their complexity, as defined by the VHWG classification, have increased over time in York Abdominal Wall Unit.

CONCLUSION

A structured pathway for complex abdominal wall hernia service is one way to improve patient experience and streamline services. The relevance of pathways for the hernia surgeon is discussed alongside this pathway. This may provide a useful guide to those wishing to establish similar personalised pathways within their own units and allow them to expand their service.

Management of complex ventral hernias: results of an international survey

Background

The surgical treatment of patients with complex ventral hernias is challenging. The aim of this study was to present an international overview of expert opinions on current practice.

Methods

A survey questionnaire was designed to investigate preoperative risk management, surgical approach and mesh choice in patients undergoing complex hernias repair, and treatment strategies for infected meshes. Geographical location of practice, experience and annual volumes of the surgeons were compared.

Results

Of 408 surgeons, 234 (57.4 per cent) were practising in the USA, 116 (28.4 per cent) in Europe, and 58 (14.2 per cent) in other countries. Some 412 of 418 surgeons (98.6 per cent) performed open repair and 322 of 416 (77.4 per cent) performed laparoscopic repair. Most recommended preoperative work-up/lifestyle changes such as smoking cessation (319 of 398, 80.2 per cent) and weight loss (254 of 399, 63.7 per cent), but the consequences of these strategies varied. American surgeons and less experienced surgeons were stricter. Antibiotics were given at least 1 h before surgery by 295 of 414 respondents (71.3 per cent). Synthetic and biological meshes were used equally in contaminated primary hernia repair, whereas for recurrent hernia repair synthetic mesh was used in a clean environment and biological or no mesh in a contaminated environment. American surgeons and surgeons with less experience preferred biological mesh in contaminated environments significantly more often. Percutaneous drainage and antibiotics were the first steps recommended in treating mesh infection. In the presence of sepsis, most surgeons favoured synthetic mesh explantation and further repair with biological mesh.

Conclusion

There remains a paucity of good-quality evidence in dealing with these hernias, leading to variations in management. Patient optimization and issues related to mesh choice and infections require well designed prospective studies.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Slowly absorbable mesh in contaminated incisional hernia repair: results of a French multicenter study

PURPOSE

To analyze the postoperative morbidity and 1-year recurrence rate of incisional hernia repair using a biosynthetic long-term absorbable mesh in patients at higher risk of surgical infection in a contaminated surgical field.

METHODS

All patients undergoing incisional hernia repair in a contaminated surgical field with the use of a biosynthetic long-term absorbable mesh (Phasix®) between May 2016 and September 2018 at six participating university centers were included in this retrospective cohort and were followed-up until September 2019. Regarding the risk of surgical infection, patients were classified according to the modified Ventral Hernia Working Group classification. Preoperative, operative and postoperative data were collected. All patients' surgical site infections (SSIs) and occurrences (SSOs) and recurrence rates were the endpoints of the study.

RESULTS

Two hundred and fifteen patients were included: 170 with mVHWG grade 3 (79%) and 45 with mVHWG grade 2 (21%). The SSI and SSO rates at 12 months were 22.3% and 39.5%, respectively. According to the Dindo-Clavien classification, 43 patients (20.0%) had at least one minor complication, and 57 patients (26.5%) had at least one major complication. Among the 121 patients (56.3%) having at least 1 year of follow-up, the clinical recurrence rate was 12.4%. Multivariate analysis showed that a concomitant gastrointestinal procedure was an independent risk factor for surgical infection (OR = 2.61), and an emergency setting was an independent risk factor for major complications (OR = 11.9).

CONCLUSION

The use of a biosynthetic absorbable mesh (Phasix®) is safe in a contaminated surgical field, with satisfying immediate postoperative and 1-year results.

TRIAL REGISTRATION

The study is registered on Clinical Trial ID: NCT04132986.

Ventral hernia repair with synthetic mesh in a contaminated field: a systematic review and meta-analysis

PURPOSE

The use of mesh in ventral hernia repair becomes especially challenging when associated with a contaminated field. Permanent synthetic mesh use in this setting is currently debated and this discussion is yet to be resolved clinically or in the literature. We aim to systematically assess postoperative outcomes of non-absorbable synthetic mesh (NASM) used in ventral hernia repair in the setting of contamination.

METHODS

A literature search of PubMed, Embase, Scopus, Cinahl, and Cochrane Library identified all articles from 2000-2020 that examined the use of NASM for ventral hernia repair in a contaminated field. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Qualitative analysis was completed for all included studies using a modified Newcastle-Ottawa scale.

RESULTS

Of 630 distinct publications and 104 requiring full review, this study included 17 articles published between 2007 and 2020. Meta-analysis demonstrated absorbable mesh was associated with more HR (OR 1.89, 1.15-3.12, p = 0.008), SSO (OR 1.43, 0.96-2.11, p = 0.087), SSI (OR 2.84, 1.85-4.35, p < 0.001), and unplanned reoperation (OR 1.99, 1.19-3.32, p = 0.009) compared to NASM.

CONCLUSION

The use of NASM for ventral hernia repair in a contaminated field may be a safe alternative to absorbable mesh, as evidenced by lower rates of postoperative complications. This review counters the current clinical paradigm, and additional prospective randomized controlled trials are warranted.

The Effects of Preoperative Botulinum Toxin A Injection on Abdominal Wall Reconstruction

BACKGROUND

Fascial closure significantly reduces postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR), but can be challenging in massive ventral hernias.

METHODS

A prospective single-institution cohort study was performed to examine the effects of preoperative injection of botulinum toxin A (BTA) in patients undergoing AWR for midline or flank hernias.

RESULTS

A total of 108 patients underwent BTA injection with average 243 units, mean 32.5 days before AWR, without complications. Comorbidities included diabetes (31%), history of smoking (27%), and obesity (mean body mass index 30.5 ± 7.7). Hernias were recurrent in 57%, massive (mean defect width 15.3 ± 5.5 cm; hernia sac volume 2154 ± 3251 cm³) and had significant loss of domain (mean 46% visceral volume outside abdominal cavity). Contamination was present in 38% of patients. Fascial closure was achieved in 91%, with 57% requiring component separation techniques (CSTs). Subxiphoidal hernias needed a form of CST in 88% compared with 50% for hernia not extending subxiphoidal (P < 0.001). Mesh augmentation was used in 98%. Postoperative complications occurred in 40%: 19% surgical site occurrences, 12% surgical site infections, and 7% respiratory failure requiring intubation, 2% mesh infection and no fascial dehiscence. Recurrence was identified in seven patients after mean 14 months of follow-up. Patients undergoing AWR with CST had more surgical site occurrences (29 versus 7%, p0.003) and respiratory failures (18 versus 0%, P = 0.002) than patients who did not require CST.

CONCLUSIONS

In patients with massive ventral hernias, the use of preoperative BTA injections for AWR is safe and is associated with high fascial closure rates and excellent recurrence rates.

Biosynthetic Resorbable Prosthesis is Useful in Single-Stage Management of Chronic Mesh Infection After Abdominal Wall Hernia Repair

BACKGROUND

The goal of this article was to report the results about the efficacy of treatment of chronic mesh infection (CMI) after abdominal wall hernia repair (AWHR) in one-stage management, with complete mesh explantation of infected prosthesis and simultaneous reinforcement with a biosynthetic poly-4-hydroxybutyrate absorbable (P4HB) mesh.

METHODS

This is a retrospective analysis of all patients that needed mesh removal for CMI between September 2016 and January 2019 at a tertiary center. Epidemiological data, hernia characteristics, surgical, and postoperative variables (Clavien-Dindo classification) of these patients were analyzed.

RESULTS

Of the 32 patients who required mesh explantation, 30 received one-stage management of CMI. In 60% of the patients, abdominal wall reconstruction was necessary after the infected mesh removal: 8 cases (26.6%) were treated with Rives-Stoppa repair, 4 (13.3%) with a fascial plication, 1 (3.3%) with anterior component separation, and 1 (3.3%) with transversus abdominis release to repair hernia defects. Three Lichtenstein (10%) and 1 Nyhus repairs (3.3%) were performed in patients with groin hernias. The most frequent postoperative complications were surgical site occurrences: seroma in 5 (20%) patients, hematoma in 2 (6.6%) patients, and wound infection in 1 (3.3%) patient. During the mean follow-up of 34.5 months (range 23-46 months), the overall recurrence rate was 3.3%. Persistent, recurrent, or new CMIs were not observed.

CONCLUSIONS

In our experience, single-stage management of CMI with complete removal of infected prosthesis and replacement with a P4HB mesh is feasible with acceptable results in terms of mesh reinfection and hernia recurrence.

Outcomes of a new slowly resorbable biosynthetic mesh (Phasix™) in potentially contaminated incisional hernias: A prospective, multi-center, single-arm trial

BACKGROUND

Resorbable biomaterials have been developed to reduce the amount of foreign material remaining in the body after hernia repair over the long-term. However, on the short-term, these resorbable materials should render acceptable results with regard to complications, infections, and reoperations to be considered for repair. Additionally, the rate of resorption should not be any faster than collagen deposition and maturation; leading to early hernia recurrence. Therefore, the objective of this study was to collect data on the short-term performance of a new resorbable biosynthetic mesh (Phasix™) in patients requiring Ventral Hernia Working Group (VHWG) Grade 3 midline incisional hernia repair.

MATERIALS AND METHODS

A prospective, multi-center, single-arm trial was conducted at surgical departments in 15 hospitals across Europe. Patients aged ≥18, scheduled to undergo elective Ventral Hernia Working Group Grade 3 hernia repair of a hernia larger than 10 cm² were included. Hernia repair was performed with Phasix™ Mesh in sublay position when achievable. The primary outcome was the rate of surgical site occurrence (SSO), including infections, that required intervention until 3 months after repair.

RESULTS

In total, 84 patients were treated with Phasix™ Mesh. Twenty-two patients (26.2%) developed 32 surgical site occurrences. These included 11 surgical site infections, 9 wound dehiscences, 7 seromas, 2 hematomas, 2 skin necroses, and 1 fistula. No significant differences in surgical site occurrence development were found between groups repaired with or without component separation technique, and between clean-contaminated or contaminated wound sites. At three months, there were no hernia recurrences.

CONCLUSION

Phasix™ Mesh demonstrated acceptable postoperative surgical site occurrence rates in patients with a Ventral Hernia Working Group Grade 3 hernia. Longer follow-up is needed to evaluate the recurrence rate and the effects on quality of life. This study is ongoing through 24 months of follow-up.

Closure of stoma site with or without prophylactic mesh reinforcement: a systematic review and meta-analysis

AIMS

To evaluate comparative outcomes of the closure of temporary stoma site with or without prophylactic mesh reinforcement METHODS: A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Studies comparing the reversal of stoma with and without prophylactic mesh reinforcement were included. Stoma site incisional hernia (SSIH), surgical site infection (SSI), operative time, seroma formation, haematoma formation, bowel obstruction, anastomosis leak, length of hospital stay (LOS) and secondary operation to repair the SSIH were the evaluated outcome parameters.

RESULTS

Six comparative studies reporting a total of 1683 patients who underwent closure of stoma with (n = 669) or without (n = 1014) prophylactic mesh reinforcement were included. Use of mesh was associated with a significantly lower risk of SSIH (OR 0.22, P = 0.003) and need for surgical intervention to repair SSIH (OR 0.32, P = 0.04) compared with no use of mesh. However, it was associated with significantly longer operative time (MD 47.78, P = 0.02). There was no significant difference in SSI (OR 1.09, P = 0.59), bowel obstruction (OR 1.11, P = 0.74), seroma formation (OR 2.86, P = 0.19), anastomosis leak (OR 1.60, P = 0.15), haematoma formation (OR 1.25, P = 0.75) or LOS (MD - 0.45, P = 0.31) between two groups.

CONCLUSION

Prophylactic mesh reinforcement during the closure of temporary stoma may significantly reduce the risk of SSIH and surgical intervention to repair the hernia without increasing the risk of SSI or other morbidities. However, it may increase the procedure time. Future higher-quality randomised evidence is required.

Use of polyvinylidene fluoride (PVDF) meshes for ventral hernia repair in emergency surgery

PURPOSE

The implantation of non-absorbable meshes is the gold standard technique for ventral hernia (VH) repairs. However, emergency surgeries are often related to contaminated/infected fields, where the implantation of prosthetic materials may not be recommendable. Our aim was to evaluate the results of polyvinylidene fluoride (PVDF) meshes used for contaminated and/or complicated VH repairs in the acute setting.

METHODS

We conducted a retrospective analysis of patients with VH who underwent emergency surgery involving PVDF meshes, in a tertiary hospital (from November 2013 to September 2019). We analyzed postoperative complications and 1-year recurrence rates. We evaluated the relationships between contamination grade, mesh placement, infectious complications, and recurrences.

RESULTS

We gathered data on 123 patients; their mean age was 62.3 years, their mean BMI was 31.1 kg/m², and their mean CeDAR index was 51.6. 96.4% of patients had a grade 2-3 ventral hernia according to the Rosen index. The mean defect width was 8 cm (IQR 2-18). 93 cases (75.6%) were described as contaminated or dirty surgeries. A PVDF mesh was placed using an IPOM technique in 56.3% of cases, and via interposition location in 39.9%. The one-month recurrence rate was 5.7% and recurrence after one year was 19.1%. The overall mortality rate was 27.6%. Risk of recurrence was related to patients with a Rosen score over 2 (p < 0.001), as well as with postoperative SSI (p = 0.045). Higher recurrence rates were not related to PVDF mesh placement.

CONCLUSION

The use of PVDF meshes for emergency VH repairs in contaminated surgeries seems safe and useful, with reasonable recurrence rates, and acceptable infectious complication rates, similar to those published in the literature.

Single-stage repair of contaminated hernias using a novel antibiotic-impregnated biologic porcine submucosa tissue matrix

Background

Single-stage repair of incisional hernias in contaminated fields has a high rate of surgical site infection (30–42%) when biologic grafts are used for repair. In an attempt to decrease this risk, a novel graft incorporating gentamicin into a biologic extracellular matrix derived from porcine small intestine submucosa was developed.

Methods

This prospective, multicenter, single-arm observational study was designed to determine the incidence of surgical site infection following implantation of the device into surgical fields characterized as CDC Class II, III, or IV.

Results

Twenty-four patients were enrolled, with 42% contaminated and 25% dirty surgical fields. After 12 months, 5 patients experienced 6 surgical site infections (21%) with infection involving the graft in 2 patients (8%). No grafts were explanted.

Conclusions

The incorporation of gentamicin into a porcine-derived biologic graft can be achieved with no noted gentamicin toxicity and a low rate of device infection for patients undergoing single-stage repair of ventral hernia in contaminated settings.

Trial registration

The study was registered March 27, 2015 at www.clinicaltrials.gov as NCT02401334.

A retrospective, Italian multicenter study of complex abdominal wall defect repair with a Permacol biological mesh

Complex abdominal wall defects (CAWDs) can be difficult to repair and using a conventional synthetic mesh is often unsuitable. A biological mesh might offer a solution for CAWD repair, but the clinical outcomes are unclear. Here, we evaluated the efficacy of a cross-linked, acellular porcine dermal collagen matrix implant (Permacol) for CAWD repair in a cohort of 60 patients. Here, 58.3% patients presented with a grade 3 hernia (according to the Ventral Hernia Working Group grading system) and a contaminated surgical field. Permacol was implanted as a bridge in 46.7%, as an underlay (intraperitoneal position) in 38.3% and as a sublay (retromuscolar position) in 15% of patients. Fascia closure was achieved in 53.3% of patients. The surgical site occurrence rate was 35% and the defect size significantly influenced the probability of post-operative complications. The long-term (2 year) hernia recurrence rate was 36.2%. This study represents the first large multi-centre Italian case series on Permacol implants in patients with a CAWD. Our data suggest that Permacol is a feasible strategy to repair a CAWD, with acceptable early complications and long-term (2 year) recurrence rates.

Long-term outcomes after contaminated complex abdominal wall reconstruction

PURPOSE

Complex abdominal wall repair (CAWR) in a contaminated operative field is a challenge. Available literature regarding long-term outcomes of CAWR comprises studies that often have small numbers and heterogeneous patient populations. This study aims to assess long-term outcomes of modified-ventral hernia working group (VHWG) grade 3 repairs. Because the relevance of hernia recurrence (HR) as the primary outcome for this patient group is contentious, the need for further hernia surgery (FHS) was also assessed in relation to long-term survival.

METHODS

A retrospective cohort study with a single prospective follow-up time-point nested in a consecutive series of patients undergoing CAWR in two European national intestinal failure centers.

RESULTS

In long-term analysis, 266 modified VHWG grade 3 procedures were included. The overall HR rate was 32.3%. The HR rates for non-crosslinked biologic meshes and synthetic meshes when fascial closure was achieved were 20.3% and 30.6%, respectively. The rates of FHS were 7.2% and 16.7%, and occurred only within the first 3 years. Bridged repairs showed poorer results (fascial closure 22.9% hernia recurrence vs bridged 57.1% recurrence). Overall survival was relatively good with 80% en 70% of the patients still alive after 5 and 10 years, respectively. In total 86.6% of the patients remained free of FHS.

CONCLUSIONS

In this study of contaminated CAWR, non-crosslinked biologic mesh shows better results than synthetic mesh. Bridging repairs with no posterior and/or anterior fascial closure have a higher recurrence rate. The overall survival was good and the majority of patients remained free of additional hernia surgery.

The development and validation of risk-stratification models for short-term outcomes following contaminated complex abdominal wall reconstruction

BACKGROUND

Short-term outcomes for patients undergoing contaminated complex abdominal wall reconstruction (CCAWR), including risk stratification, have not been studied in sufficiently high numbers. This study aims to develop and validate risk-stratification models for Clavien-Dindo (CD) grade ≥ 3 complications in patients undergoing CCAWR.

METHODS

A consecutive cohort of patients who underwent CCAWR in two European national intestinal failure centers, from January 2004 to December 2015, was identified. Data were collected retrospectively for short-term outcomes and used to develop risk models using logistic regression. A further cohort, from January 2016 to December 2017, was used to validate the models.

RESULTS

The development cohort consisted of 272 procedures performed in 254 patients. The validation cohort consisted of 114 patients. The cohorts were comparable in baseline demographics (mean age 58.0 vs 58.1; sex 58.8% male vs 54.4%, respectively). A multi-variate model including the presence of intestinal failure (p < 0.01) and operative time (p < 0.01) demonstrated good discrimination and calibration on validation. Models for wound and intra-abdominal complications were also developed, including pre-operative immunosuppression (p = 0.05), intestinal failure (p = 0.02), increasing operative time (p = 0.04), increasing number of anastomoses (p = 0.01) and the number of previous abdominal operations (p = 0.02). While these models showed reasonable ability to discriminate patients on internal assessment, they were not found to be accurate on external validation.

CONCLUSION

Acceptable short-term outcomes after CCAWR are demonstrated. A robust model for the prediction of CD ≥ grade 3 complications has been developed and validated. This model is available online at www.smbari.co.uk/smjconv2.

Absorbable Polyglactin vs. Non-Cross-linked Porcine Biological Mesh for the Surgical Treatment of Infected Incisional Hernia

BACKGROUND

The use of absorbable meshes during contaminated or infected incisional hernia (IH) repair is associated with high morbidity and recurrence rates. Biological meshes might be more appropriate but have been described in highly heterogeneous series. This study aimed at comparing the efficacy of absorbable vs. biological meshes for the treatment of contaminated or infected IH in a homogeneous series with a standardized technique.

METHODS

Data of all patients operated on between 2008 and 2015 for contaminated or infected IH, using an absorbable (A) Vicryl® or a biological (B) Strattice® mesh, were reviewed. Patient characteristics, infectious complication rates, and recurrence-free outcome (RFO) were compared between the two groups. A propensity score methodology was applied to a Cox regression model to deal with unbalanced characteristics between groups.

RESULTS

Patient demographics in A (n = 57) and in B (n = 24) were similar except that B patients had larger parietal defects (p < 0.001) and higher Center for Disease Control (CDC) wound class (p = 0.034). Patients in A had statistically significantly more postoperative early (61.4% vs. 33.3%, p = 0.03) and late (31.2% vs. 8.3%, p = 0.046) infectious complications. Six-, 12-, and 36-month RFO rates were 77%, 47%, and 24%, and 96%, 87%, and 82% in A and B, respectively, p < 0.001. Raw multivariable Cox regression analysis found that B (HR = 0.1, 95% CI [0.03-0.34], p < 0.001) was independently associated with prolonged RFO (HR = 0.091, 95% CI [0.045-0.180], p < 0.001).

CONCLUSION

Biological meshes seem to be superior to absorbable meshes in patients with contaminated or infected incisional hernia. These results need to be confirmed by prospective randomized trials.

Timing of repair and mesh use in traumatic abdominal wall defects: a systematic review and meta-analysis of current literature

Background

Traumatic abdominal wall hernias or defects (TAWDs) after blunt trauma are rare and comprehensive literature on this topic is scarce. Altogether, there is no consensus about optimal methods and timing of repair, resulting in a surgeon’s dilemma. The aim of this study was to analyze current literature, comparing (1) acute versus delayed repair and (2) mesh versus no mesh repair.

Methods

A broad and systematic search was conducted in PubMed, EMBASE, and the Cochrane Library. The selected articles were assessed on methodological quality using a modified version of the CONSORT 2010 Checklist and the Newcastle-Ottawa scale. Primary endpoint was hernia recurrence, diagnosed by clinical examination or CT. Random effects meta-analyses on hernia recurrence rates after acute versus delayed repair, and mesh versus no mesh repair, were conducted separately.

Results

In total, 19 studies were evaluated, of which 6 were used in our analysis. These studies reported a total of 229 patients who developed a TAWD, of whom a little more than half underwent surgical repair. Twenty-three of 172 patients (13%) who had their TAWD surgically repaired developed a recurrence. In these studies, nearly 70% of the patients who developed a recurrence had their TAWD repaired primarily without a mesh augmentation and mostly during the initial hospitalization. Pooled analysis did not show any statistically significant favor for either use of mesh augmentation or the timing of surgical repair.

Conclusion

Although 70% of the recurrences occurred in patients without mesh augmentation, pooled analysis did not show significant differences in either mesh versus no mesh repair, nor acute versus delayed repair for the management of traumatic abdominal wall defects. Therefore, a patient’s condition (e.g., concomitant injuries) should determine the timing of repair, preferably with the use of a mesh augmentation.

Comparison of biosynthetic versus synthetic mesh in clean and contaminated ventral hernia repairs

BACKGROUND

Abdominal hernias are an increasingly common presentation due to obesity, ageing and prevalence of prior abdominal surgery. Mesh repair is the mainstay of treatment; however, mesh selection remains largely subjective. There are little data available to assess the performance of biosynthetic meshes against synthetic meshes across all wound types. This study assessed the 6-month outcomes of a single surgeon's cohort of ventral hernia repairs performed with either GORE BIO-A (BioA) or Parietex ProGrip (ProGrip).

METHODS

Retrospective case cohort study across two centres with patients undergoing repair by a single surgeon (KS) between January 2014 and April 2018 was conducted. All hernia repairs were performed with either BioA (n = 55) or ProGrip mesh (n = 60). Outcomes were monitored for 6 months post repair. Wounds were classified according to the Centre for Disease Control Wound Status. Outcomes measured were length of stay, general complications, wound complications and hernia recurrence.

RESULTS

The overall complication rate and length of stay were similar for both groups. In clean wounds, the complication rate was equivalent for BioA and ProGrip (34% versus 22%, P = 0.22). There was a significant difference in complication rates in contaminated wounds - BioA 17% versus ProGrip 100% (P = 0.004). BioA performed equivocally in clean and contaminated wounds (34% versus 17%, P = 0.178), whereas ProGrip performed worse in contaminated wounds (22% versus 100%, P = 0.016).

CONCLUSION

Our results suggest that BioA is a suitable, if not preferable, choice for contaminated hernia repair. In this cohort, BioA was also demonstrated as safe and equivalent to ProGrip mesh in clean hernia wounds.

Management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience

INTRODUCTION

Traumatic abdominal wall defects (TAWDs) following blunt trauma are uncommon injuries with an incidence reported less than 1%. Improved diagnostics and subsequent early detection of otherwise rare injuries raise more questions concerning their treatment. There is lack of consensus on treatment and timing of TAWD. The aim of this study was to analyse the management strategy and outcomes of these injuries in our level I trauma centre.

METHODS

All trauma patients who presented with a TAWD at our trauma centre between 2007 and 2016 were retrospectively reviewed. Blunt abdominal wall injuries were classified, patient characteristics, concomitant injuries and treatment characteristics were recorded. In addition, telephone surveys were conducted to assess patient reported quality of life.

RESULTS

In a period of nearly ten years 21 patients with a TAWD were treated in our hospital, approximately 0.17% of all admitted trauma patients. Seventeen patients were classified as polytrauma patient. Seventeen patients underwent surgical repair in whom 5 recurrences occurred. All of the recurrences were in patients treated without mesh repair (p = 0.03). The quality of life in terms of EQ-VAS was similar for patients treated with and without mesh repair and reasonable when compared to the reference population. Overall quality of life was lower compared to the reference population, mainly due to limitations in daily activities, mobility and pain.

CONCLUSION

Using mesh in the treatment of TAWD, in our hands, showed significantly less recurrences compared to primary closure. We therefore recommend the use of mesh in the repair of TAWDs, both in the acute as well as in the delayed setting when feasible.

Comparative study of peritoneal adhesions after intraperitoneal implantation in rats of meshes of polypropylene versus polypropylene/polyglecaprone versus polyester/porcine collagen

PURPOSE

To Compare the extent and intensity of adhesions formed between the intra-abdominal organs and the intraperitoneal implants of polypropylene mesh versus polypropylene/polyglecaprone versus polyester/porcine collagen used for correction of abdominal wall defect in rats.

METHODS

After the defect in the abdominal wall, thirty Wistar rats were placed in three groups (ten animals each) for intraperitoneal mesh implant: polypropylene group, polypropylene/polyglecaprone group, and polyester/porcine collagen group. The macroscopic evaluation of the extent and intensity of adhesions was performed 21 days after the implant.

RESULTS

The polypropylene group had a higher statistically significant impairment due to visceral adhesions (p value = 0.002) and a higher degree of intense adherence in relation to polypropylene/polyglecaprone and polyester/porcine collagen groups (p value<0.001). The polyester/porcine collagen group showed more intense adhesions than the polypropylene/polyglecaprone group (p value=0.035).

CONCLUSIONS

The intraperitoneal implantation of polypropylene meshes to correct defects of the abdominal wall caused the appearance of extensive and firm adhesions to intra-abdominal structures. The use of polypropylene/polyglecaprone or polyester/porcine collagen tissue-separating meshes reduces the number and degree of adhesions formed.

Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis

Purpose

To provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes.

Methods

A literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles.

Results

A number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21 months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04–0.27, p < 0.001, I² = 0%, CI 0–91.40%). No differences in surgical site infections were detected between the groups.

Conclusions

The use of a prophylactic mesh seems to reduce the risk on incisional hernias after stoma reversal and therefore mesh reinforcement should be considered after stoma reversal.

Electronic supplementary material

The online version of this article (10.1007/s10029-019-01996-8) contains supplementary material, which is available to authorized users.