Laparoscopic and open incisional hernia repair using polypropylene mesh - A comparative single centre study

Non-closure of the Free Peritoneal Flap During Laparoscopic Hernia Repair of Lower Abdominal Marginal Hernia: A Retrospective Analysis

Background: During lower abdominal marginal hernia repair, the peritoneal flap is routinely freed to facilitate mesh placement and closed to conclude the procedure. This procedure is generally called trans-abdominal partial extra-peritoneal (TAPE). However, the necessity of closing the free peritoneal flap is still controversial. This study aimed to investigate the safety and feasibility of leaving the free peritoneal flap in-situ. Methods: A retrospective review was conducted on 68 patients (16 male, 52 female) who underwent laparoscopic hernia repair between June 2014 and March 2021. Patients were diagnosed as the lower abdominal hernia and all required freeing the peritoneal flap during the operation. Patients were divided into 2 groups: one group was TAPE group with the closed free peritoneal flap, another group left the free peritoneal flap unclosed. Analyses were performed to compare both intraoperative parameters and postoperative complications. Results: There were no significant differences in demographic, comorbidity, hernia characteristics and ASA classification. The intra-operative bleeding volume, visceral injury, hospital stay, urinary retention, visual analog scale (VAS) score, dysuria, intestinal obstruction, surgical site infection, mesh infection, recurrence rate and hospital stay were similar among the two groups. Mean operative time of the flap closing procedure was higher than for patients with the free peritoneal flap left in-situ (p = 0.002). Comparisons of postoperative complications showed flap closure resulted in a higher incidence of seroma formation (p = 0.005). Conclusion: Providing a barrier-coated mesh is used during laparoscopic lower abdominal marginal hernia repair, it is safe to leave the free peritoneal flap in-situ and this approach may prevent the occurrence of seromas.

A systematic review of outcome reporting in incisional hernia surgery

Background

The incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies.

Methods

Literature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included.

Results

In total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used.

Conclusions

This review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

A systematic methodological review of non-randomised interventional studies of elective ventral hernia repair: clear definitions and a standardised minimum dataset are needed

BACKGROUND

Ventral hernias (VHs) often recur after surgical repair and subsequent attempts at repair are especially challenging. Rigorous research to reduce recurrence is required but such studies must be well-designed and report representative and comprehensive outcomes.

OBJECTIVE

We aimed to assesses methodological quality of non-randomised interventional studies of VH repair by systematic review.

METHODS

We searched the indexed literature for non-randomised studies of interventions for VH repair, January 1995 to December 2017 inclusive. Each prospective study was coupled with a corresponding retrospective study using pre-specified criteria to provide matched, comparable groups. We applied a bespoke methodological tool for hernia trials by combining relevant items from existing published tools. Study introduction and rationale, design, participant inclusion criteria, reported outcomes, and statistical methods were assessed.

RESULTS

Fifty studies (17,608 patients) were identified: 25 prospective and 25 retrospective. Overall, prospective studies scored marginally higher than retrospective studies for methodological quality, median score 17 (IQR: 14-18) versus 15 (IQR 12-18), respectively. For the sub-categories investigated, prospective studies achieved higher median scores for their, 'introduction', 'study design' and 'participants'. Surprisingly, no study stated that a protocol had been written in advance. Only 18 (36%) studies defined a primary outcome, and only 2 studies (4%) described a power calculation. No study referenced a standardised definition for VH recurrence and detection methods for recurrence varied widely. Methodological quality did not improve with publication year or increasing journal impact factor.

CONCLUSION

Currently, non-randomised interventional studies of VH repair are methodologically poor. Clear outcome definitions and a standardised minimum dataset are needed.

Investigation into the optimal prosthetic material for wound healing of abdominal wall defects

The purpose of this experimental study is to investigate and compare the effects of prosthetic materials used for wound healing of abdominal wall hernias. A total of 60 rats were divided into five equal groups: Group I, control subjected to laparotomy; group II, abdominal wall defect 3×2 cm+polypropylene (PP) mesh; group III, abdominal wall defect 3×2 cm+PP mesh+hyaluronate and carboxymethylcellulose (H-CMC; Seprafilm^®); group IV, abdominal wall defect 3×2 cm+polytetrafluoroethylene (PTFE; Composix^™); and group V, abdominal wall defect 3×2 cm+polyethylene terephthalate (PET; Dacron^®). A total of 14 days after the surgery, rats were sacrificed and the meshes with the surrounding tissue were extracted in block. The breaking strength of the mesh from the fascia was recorded. The healing tissue was examined with the index of histopathology and the hydroxyproline value was analyzed using the Switzer method. Both the breaking strength and histopathological index of the wound healing were significantly improved in groups II and III compared with that in groups IV and V (P<0.001). Hydroxyproline values were the highest in group I (P<0.001). There was also a statistically significant difference between groups II and IV, and group V and the other groups (P<0.001). The present findings demonstrated that PP mesh and PP mesh+H-CMC had a superior breaking strength and improved histopathologic indices compared with PTFE and PET. Furthermore, hydroxyproline values were the lowest in the PET group. In conclusion, wound healing was improved in the PP mesh group and the PP mesh+H-CMC group compared with the PTFE and PET groups according to the present study parameters.

Physical and mathematical modelling of implant-fascia system in order to improve laparoscopic repair of ventral hernia

BACKGROUND

This paper describes an investigation of biomechanical behaviour of hernia repair, which is focused on the selection of safe linking of certain type of implant with fascia in laparoscopic operation. The strength of various fixations of the implant to the fascia is analysed.

METHODS

The research is based on experimental observations of operated hernia model behaviour during a dynamic impulse load corresponding to post-operative cough. Fifty seven different types of models of implanted mesh are considered. Five types of implants and five types of connectors are used. Mechanical properties of the implants as well as limit tearing forces of joints are identified in uni-axial tensile tests. Mathematical model of implanted mesh based on finite element method is proposed. The identified mechanical properties of the materials are applied and the model is calibrated using quantities measured during experiments.

FINDINGS

The presented results point at trans-abdominal sutures and ProTacks (connectors) and at DynaMesh (implant) as the most reliable materials used in ventral hernia operation, in the tested materials group. Desired properties of implants seem to be: elastic properties similar to the properties of tissues and high local strength, as fixation have a local character. The proposed mathematical model can be applied to simulate real behaviour of an implant with appropriate accuracy and to estimate the number of tacks for the implantation of hernia meshes.

INTERPRETATION

The presented results may help in the deeper understanding of the fascia-mesh system behaviour, and thus may lead to improve the fixation methods.

Repair of large and giant incisional hernia with onlay mesh: perspective of a tertiary care hospital of a developing country

PURPOSE

Ventral incisional hernias, especially large and giant, carry significant post repair complications. This retrospective review is undertaken to determine the outcomes of large and giant incisional hernia repair as well as the risk factors of recurrence and surgical site infection at a tertiary care hospital in developing country.

METHOD

This case series included adult patients, operated between January 2001 and June 2009 for incisional hernia of size ≥ 10 cm (vertical or horizontal dimension) at our institute with follow up of at least one year. The charts of selected patients were reviewed by a general surgery fellow for hernia recurrence, complications, mortality and the predictive factors.

RESULTS

Sixty out of 391 patients operated for incisional hernia were found eligible; of them 29 (48.3%) had large (defect of 10-15 cm) and 31 (51.7%) had giant hernia (defect size >15 cm). Mean age of patients was 43.8 ± 11.8 with female preponderance (male: female; 1:1.6). Fourteen (23.33%) patients developed complications and there was no mortality. Surgical Site Infection (SSI) was observed in 13 (21.67%) patients and significant predisposing factors for SSI (with or without mesh infection) were diabetes mellitus, emergency surgery, contaminated surgery and recurrent incisional hernia. With a mean follow up of 20.05 ± 8.8 months (range: 12-48 months), four (6.67%) patients had recurrence of hernia.

CONCLUSIONS

Repair of large and giant incisional hernia using prosthetic non-absorbable mesh, mainly onlay, carry acceptable rates of complications.

Investigation of abdomen surface deformation due to life excitation: implications for implant selection and orientation in laparoscopic ventral hernia repair

BACKGROUND

Ventral hernia is a common medical problem. Statistically there are around 10% recurrences of the sickness. The authors' former investigation proved edges of the hernia orifice displacements to be one of the factors causing recurrence. Thus, experimental investigation of the abdomen surface deformation due to some normal activities of people is studied.

METHODS

Eight slim, healthy people were asked to extremely stretch their abdomens. Bending, stretching and expiration were considered. The deformations registration was made by two cameras located in front of the patient on both sides. Special calculation procedure was used in order to transform characteristic point displacements to strains of abdomen in different directions.

FINDINGS

The extreme strains, their localization and directions are identified. The study proves that the highest strains, bigger than 25% on average, appear in the upper part of the central vertical line of the abdomen and in lower sides in semi-vertical direction. The lowest strains, smaller than 7%, occur in a horizontal line situated low in the abdomen. For each patient similar zones of smaller or bigger strains are identified, however a wide discrepancy of the strain values obtained for different patients is stated. For example the strains in lower part in semi-vertical direction for one patient equals 9% and for another 134%!

INTERPRETATION

The acquired conclusions may be useful for surgeons in finding practical solutions to dilemmas concerning the choice of an implant (elastic or stiff) for a specific ventral hernia, its proper connection with fascia and orientation in the abdomen.