Bilateral transversus abdominis release: Complex hernia repair without sacrificing quality of life

Transversus abdominis release with biosynthetic mesh for large ventral hernia repair: a 5-year analysis of clinical outcomes and quality of life

INTRODUCTION

Transversus abdominis release (TAR) may provide an optimal plane for mesh placement for large ventral hernias requiring medial myofascial flap advancement. Long-term outcomes of TAR for large ventral hernia repair (VHR) remains under-studied. This study aims to assess longitudinal clinical outcomes and quality of life (QoL) following large VHR with TAR and resorbable biosynthetic mesh.

METHODS

Retrospective review of clinical outcomes and prospective QoL was performed for patients undergoing VHR with poly-4-hydroxybutyrate mesh and TAR from 2016 to 2021. Patients with ≤ 24 months of follow-up, defects ≤ 150 cm2, and parastomal hernias were excluded. Cost-related data was collected for each patient's hospital course. QoL was compared using paired Wilcoxon signed-rank tests.

RESULTS

Twenty-nine patients met inclusion criteria. Median age and BMI were 61 years (53.2-68.1 years) and 31.4 kg/m2 (26.1-35.3 kg/m2). Average hernia defect was 390cm2 ± 152.9 cm2. All patients underwent previous abdominal surgery and were primarily Ventral Hernia Working Group 2 (58.6%). Two hernia recurrences (6.9%) occurred over the median follow-up period of 63.1 months (IQR 43.7-71.3 months), with no cases of mesh infection or explantation. Delayed healing and seroma occurred in 27 and 10.3% of patients, respectively. QoL analysis identified a significant improvement in postoperative QoL (p < 0.005), that continued throughout the 5-year follow-up period, with a 41% overall improvement. Cost analysis identified the hospital revenue generated was approximately equal to the direct costs of patient care. Higher costs were associated with ASA class and length of stay (p < 0.05).

CONCLUSION

Large VHR with resorbable biosynthetic mesh and TAR can be performed safely, with a low recurrence and complication rate, acceptable hospital costs, and significant improvement in disease-specific QoL at long-term follow-up.

Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis

INTRODUCTION

Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy.

METHODS

A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed.

RESULTS

Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores.

CONCLUSIONS

Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

Is weight trajectory a better marker of wound complication risk than BMI in hernia patients with obesity?

BACKGROUND

Complex ventral hernias are frequently repaired via an open transversus abdominis release (TAR). Obesity, particularly a BMI > 40, is a strong predictor of wound morbidity following this procedure. We aimed to determine if preoperative weight loss may still be beneficial in patients with persistently elevated BMIs.

METHODS

A retrospective chart review of patients with obesity (BMI ≥ 30) who underwent open TAR at a tertiary academic medical center from January 2018 to December 2021 was completed. Demographics, medical history, operative details, and postoperative data were analyzed. Weight and BMI were recorded at three time points: > 6 months prior to initial surgical consultation, surgical consultation, and day of surgery.

RESULTS

In total, 182 patients with obesity underwent an open TAR. Twenty-seven patients (14.8%) underwent surgery with a BMI > 40; they did not have any significant differences in surgical site occurrences (SSO, 48.1% vs 32.9%, p = 0.13) or surgical site infections (SSI, 25.9% vs 23.2%, p = 0.76) compared to those with a BMI ≤ 40. The average timeframe analyzed for preoperative weight loss was 592 days. Patients who had at least a 3% weight loss (n = 49, 26.9%) had decreased rates of SSI compared to those who did not have this weight loss (12.2% vs 27.8%, p = 0.03), despite the groups having similar BMIs at the time of surgery (36.4 vs 36.0, p = 0.50). Patients who only had a 1% weight loss did not see a decrease in SSI rate compared to those who did not (20.6% vs 25.4%, p = 0.45).

CONCLUSION

Weight loss may be a better indicator of a patient's risk for wound morbidity following TAR than BMI alone, as weight loss of at least 3% resulted in fewer SSIs despite similar BMIs at time of surgery. Further research into optimal timing and amount of weight loss, as well as effects on long-term outcomes, is needed to confirm these findings.

National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery

PURPOSE

It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS).

METHODS

Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression.

RESULTS

Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01).

CONCLUSION

IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.

How-I-do-it: minimally invasive repair of ileal conduit parastomal hernias

BACKGROUND

Parastomal hernia after radical cystectomy and ileal conduit urinary diversion is an underestimated and undertreated condition with significant impact on quality of life. However, its surgical treatment is challenging and prone to complications and the optimal surgical treatment of this condition remains to be determined.

METHODS

In this article, we describe our surgical techniques in the minimally invasive treatment of ileal conduit parastomal hernia and present our preliminary results. In a retrospective single-center design, a prospectively maintained database was screened. Data from all patients undergoing surgical treatment for a parastomal hernia after cystectomy and ileal conduit urinary diversion in our center were collected.

RESULTS

Between May 2016 and June 2020, 15 patients underwent minimally invasive repair of a parastomal hernia of an ileal conduit. Details on the surgical approach are provided, along with a flow chart to standardize the choice of surgical technique, depending on the presence of a concomitant midline incisional hernia and perioperative findings. The majority of patients were treated with robotic-assisted laparoscopic surgery (10/15; 66.7%). Median postoperative hospital stay was 5 days. One-third of patients developed a postoperative urinary infection. Median follow-up was 366 days. One patient developed a local recurrence of her parastomal hernia on day 66 postoperatively, treated with intraperitoneal mesh.

CONCLUSION

The minimally invasive surgical treatment of a parastomal hernia after ileal conduit urinary diversion poses specific perioperative challenges that require a broad surgical armamentarium and a tailored approach. Preliminary results confirm a significant morbidity after this type of surgery.

Longitudinal Clinical and Patient-Reported Outcomes After Transversus Abdominis Release for Complex Hernia Repair With a Review of the Literature

PURPOSE

Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR.

METHODS

Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed.

RESULTS

Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m², respectively. The average hernia defect was 384 cm² [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05).

CONCLUSION

Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.