A systematic review of laparoscopic versus open abdominal incisional hernia repair, with meta-analysis of randomized controlled trials

The initial experience of robot-assisted transabdominal transversalis fascial and preperitoneal repair for small ventral hernia

PURPOSE

Despite the widespread of ventral hernia repairs globally, the approach method, dissection planes, defect closure, and the choice and placement layer of mesh are an ongoing debate. We reported the details of surgical techniques, safety and feasibility for robot-assisted transabdominal transversalis fascial and preperitoneal repair (R-TATFPP) for small ventral hernia.

METHODS

This study included 5 cases of R-TATFPP repair among 22 cases performed by robot-assisted ventral hernia repair from 2018 to 2023 with the approval of the Institutional Review Board at St. Luke's International University and clinical ethical committee at St. Luke's International Hospital (19-R147, 22-012).

RESULTS

There were four males and one female, with mean age of 64.4 ± 10.0 years, inclusive of two umbilical and three incisional hernias. Mean height, weight, body mass index (BMI), hernia defect length, width, operation time, console time, and hospital stay were 171.2 ± 11.8 cm, 82.4 ± 13.4 kg, 28.0 ± 2.1 kg/m2, 2.8 ± 1.4 cm, 3.0 ± 1.3 cm, 180 min, 133.8 min, and 2.4 days, respectively. No conversion nor complication was observed except for one acute urinary retention.

CONCLUSION

Robot-assisted transversalis fascial and preperitoneal repair was safe and feasible for small ventral hernia with the minimal disruption to the abdominal wall architecture and structures.

Advancing geriatric surgical outcomes in elective ventral and incisional hernia repair surgeries: An American college of surgeons national surgical quality improvement program study

INTRODUCTION

Increasing age is known to be associated with increased risk for postoperative morbidity and mortality, however, the goal of this study was to determine if an increase in age correlates to differences in surgical outcomes for elective ventral hernia repair.

METHODS

Retrospective cohort study using American College of Surgeons NSQIP database from 2016 to 2020. Included diagnosis codes were laparoscopic or open incisional or ventral hernia repairs, categorized into three age groups: 18-64y, 65-74y, and ≥75y. Thirty-day perioperative outcomes analyzed using bivariate χ2 test and multivariate logistic regression.

RESULTS

We identified 116,643 people who had elective ventral or incisional hernia repair. Compared to 18-64y and 65-74y age groups, patients ≥75y were significantly more likely to develop any post-operative complication, be re-admitted post-operatively for any reason, have an extended hospital stay, and require a reoperation.

CONCLUSIONS

Patients ≥75y have significantly higher rates of perioperative complications after elective hernia repair compared to younger patients.

Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias

INTRODUCTION

Intraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs.

METHODS AND PROCEDURES

Adult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively.

RESULTS

A total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8-5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up.

CONCLUSION

Intraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.

Does intraperitoneal mesh increase the risk of bowel obstruction? A nationwide French analysis

INTRODUCTION

Incisional hernias are associated with a reduced quality of life. Mesh reinforcement of the abdominal wall is the current standard for incisional hernia repair (IHR), since it reduces the risk of recurrence. The best position for the mesh remains controversial, and each position has advantages and disadvantages.

OBJECTIVE

In this nationwide population-based study, we aimed to determine whether IHR with intraperitoneal mesh is associated with an increased risk of bowel obstruction.

PATIENTS AND METHODS

Using the French hospital database (PMSI), which collects data from all public and private hospitals, two patient cohorts were created and compared. Patients having undergone a laparoscopic IHR with intraperitoneal mesh (IPOM) in 2013 or 2014 due to a laparotomy performed in the 4 previous years were the IPOM group. Patients hospitalized for any other acute disease (i.e., without IHR) in 2013 and 2014, but having a similar laparotomy in the 4 previous years were the control group. Both cohorts were followed until 2019 in search of any episode of bowel obstruction.

RESULTS

A total of 815 patients were included in the IPOM group and matched to 1630 control patients. The 5 year bowel obstruction rate was 7.36% in the IPOM group and 4.42% in the control group (p < 0.01). In the multivariate analysis, after adjustment on age and obesity, incisional hernia repair with laparoscopic IPOM increased the risk of bowel obstruction in the 5 years following surgery (HR = 1.712; 95% CI 1.208-2.427; p = 0.0025).

CONCLUSIONS

Patients having undergone laparoscopic IPOM have an increased risk of bowel obstruction compared with patients who have a similar surgical history but no IHR.

Are Surgeons Going to Be Left Holding the Bag? Incisional Hernia Repair and Intra-Peritoneal Non-Absorbable Mesh Implant Complications

Ventral incisional hernias are common indications for elective repair and frequently complicated by recurrence. Surgical meshes, which may be synthetic, bio-synthetic, or biological, decrease recurrence and, resultingly, their use has become standard. While most patients are greatly benefited, mesh represents a permanently implanted foreign body. Mesh may be implanted within the intra-peritoneal, preperitoneal, retrorectus, inlay, or onlay anatomic positions. Meshes may be associated with complications that may be early or late and range from minor to severe. Long-term complications with intra-peritoneal synthetic mesh (IPSM) in apposition to the viscera are particularly at risk for adhesions and potential enteric fistula formation. The overall rate of such complications is difficult to appreciate due to poor long-term follow-up data, although it behooves surgeons to understand these risks as they are the ones who implant these devices. All surgeons need to be aware that meshes are commercial devices that are delivered into their operating room without scientific evidence of efficacy or even safety due to the unique regulatory practices that distinguish medical devices from medications. Thus, surgeons must continue to advocate for more stringent oversight and improved scientific evaluation to serve our patients properly and protect the patient-surgeon relationship as the only rationale long-term strategy to avoid ongoing complications.

Short-term outcomes after open versus robot-assisted repair of ventral hernias: a nationwide database study

PURPOSE

The robotic platform is widely implemented; however, evidence evaluating outcomes of robotic ventral hernia repair is still lacking. The aim of the study was to evaluate the short-term outcomes after open and robot-assisted repair of primary ventral and incisional hernias.

METHODS

Nationwide register-based cohort study with data from the Danish Ventral Hernia Database and the National Danish Patients Registry was from January 1, 2017 to August 22, 2022. Robot-assisted ventral hernia repairs were propensity score matched 1:3 with open repairs according to the confounding variables defect size, Charlson comorbidity index score, and age. Logistic regression analyses were performed for factors associated with length of stay > 2 days, readmission, and reoperation within 90 days.

RESULTS

A total of 528 and 1521 patients underwent robot-assisted and open repair, respectively. The mean length of hospital stay in days was 0.5 versus 2.1 for robot-assisted and open approach, respectively (P < 0.001) and open approach was correlated with risk of length of stay > 2 days (OR 23.25, CI 13.80-39.17, P < 0.001). The incidence of readmission within 90 days of discharge was significantly lower after robot-assisted repair compared to open approach (6.2% vs. 12.1%, P < 0.001). Open approach was independently associated with increased risk of readmission (OR 21.43, CI 13.28-39.17, P = 0.005, P < 0.001).

CONCLUSION

Robot-assisted ventral hernia repair is safe and feasible and associated with shorter length of stay and decreased risk of readmission compared with open ventral hernia repair.

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.

Mini- or less-open sublay (E/MILOS) operation vs open sublay and laparoscopic IPOM repair for the treatment of incisional hernias: a registry-based propensity score matched analysis of the 5-year results

BACKGROUND

Open sublay and laparoscopic IPOM repair have specific disadvantages and risks. In recent years, this evidence led to a paradigm shift and induced the development of new minimally invasive techniques of sublay mesh repair.

METHODS

Pioneering this trend, we developed the endoscopically assisted mini- or less-open sublay (MILOS) concept. The operation is performed trans-hernially via a small incision with light-holding laparoscopic instruments either under direct, or endoscopic visualization. After dissection of an extra-peritoneal space of at least 8 cm, port placement and CO2 insufflation, each MILOS operation can be continued endoscopically (EMILOS repair). All E/MILOS operations were prospectively documented in the Herniamed Registry with 1- and 5-year questionnaire follow-ups. Propensity score matching of incisional hernia operations comparing the results of the E/MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from all other institutions participating in the Herniamed Registry was performed. The results with perioperative complications and 1-year follow-up have been published previously.

RESULTS

This paper reports on the 5-year results. The 5-year follow-up rate was 87.5% (538 of 615 patients with E/MILOS incisional hernia operations). Comparing E/MILOS repair with laparoscopic IPOM and open sublay operation, propensity score matching analysis was possible with 448 and 520 pairs of operations, respectively. Compared with laparoscopic IPOM incisional hernia operation, the E/MILOS repair is associated with significantly fewer general complications (P = 0.004), recurrences (P < 0.001), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.016) and tends to result in fewer postoperative complications (P = 0.052), and less pain at rest (P = 0.053). Matched pair analysis with open sublay repair revealed significantly fewer general complications (P < 0.001), postoperative complications (P < 0.001), recurrences (P = 0.002), less pain at rest (P = 0.004), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.014). A limitation of this analysis is a relative low 5-year follow-up rate for laparoscopic IPOM and open sublay.

CONCLUSIONS

The E/MILOS technique allows minimally invasive trans-hernial repair of incisional hernias using large standard meshes with low morbidity and good long-term results. The technique combines the advantages of sub-lay repair and a mini- or less-invasive approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03133000.

Preoperative CT imaging as a tool to predict incisional hernia outcomes following abdominal wall reconstruction: A retrospective cohort analysis

INTRODUCTION

Ventral wall hernia often causes significant morbidity and requires complex abdominal wall reconstruction (AWR). This study aims to determine whether subcutaneous abdominal fat thickness (AFT) measured with preoperative CT scans could predict postoperative outcomes in patients undergoing AWR.

METHODS

A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021, with a minimum follow-up of 12 months. Using preoperative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analyzed using statistical tests.

RESULTS

The results showed that 9 of 101 patients (8.9%) experienced hernia recurrence. Smoking was associated with an increased risk of hernia recurrence (p < 0.001) with a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus (p < 0.001), and pubic tubercle (p < 0.001) were also associated with hernia recurrence and risk of infection. Only AFT at the pubic tubercle reached significance in the regression model predicting recurrence (OR=1.10; p = 0.030) and infection (OR=1.04; p = 0.021). A cut-off value of 67 mm was associated with a positive predictive value of 42.14% (sensitivity of 67% and specificity of 91%). Hernia defect area was not associated with risk of recurrence or infection.

CONCLUSIONS

Smoking and increased AFT at the pubic tubercle are significant predictive factors for recurrence and infection in patients undergoing AWR, and preoperative optimization should focus on reducing these factors.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Body Mass Index Effect on Minimally Invasive Ventral Hernia Repair: A Systematic Review and Meta-analysis

PURPOSE

Obesity is one of the most important risk factors for complications after ventral hernia repair (VHR), and minimally invasive (MIS) techniques are preferred in obese patients as they minimize wound complications. It is common practice to attempt weight loss to achieve a specific body mass index (BMI) goal; however, patients are often unable to reach it and fail to become surgical candidates. Therefore, we aim to perform a meta-analysis of studies comparing outcomes of obese and nonobese patients undergoing laparoscopic or robotic VHR.

PATIENTS AND METHODS

A literature search of PubMed, Scopus, and Cochrane Library databases was performed to identify studies comparing obese and nonobese patients undergoing MIS VHR. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics.

RESULTS

A total of 6483 studies were screened and 26 were thoroughly reviewed. Eleven studies and 3199 patients were included in the meta-analysis. BMI >40 kg/m 2 cutoff analysis included 5 studies and 1533 patients; no differences in hernia recurrence [odds ratios (OR): 1.64; 95% CI: 0.57-4.68; P = 0.36; I2 = 47%), seroma, hematoma, and surgical site infection (SSI) rates were noted. BMI >35 kg/m 2 cutoff analysis included 5 studies and 1403 patients; no differences in hernia recurrence (OR: 1.24; 95% CI: 0.71-2.16; P = 0.58; I2 = 0%), seroma, hematoma, and SSI rates were noted. BMI >30 kg/m 2 cutoff analysis included 4 studies and 385 patients; no differences in hernia recurrence (OR: 2.07; 95% CI: 0.5-8.54; P = 0.32; I2 = 0%), seroma, hematoma, and SSI rates were noted.

CONCLUSION

Patients with high BMI undergoing MIS VHR have similar hernia recurrence, seroma, hematoma, and SSI rates compared with patients with lower BMI. Further prospective studies with long-term follow-up and patient-reported outcomes are required to establish optimal management in obese patients undergoing VHR.

Comparative effectiveness of hybrid and laparoscopic techniques for repairing complex incisional ventral hernias: a systematic review and meta-analysis

BACKGROUND

The recently developed Hybrid Hernia Repair technique (HHR), an adaptation of the laparoscopic method, has been proposed as a potential alternative for the treatment of complex Incisional Ventral Hernias (IVH). While single-arm studies have reported promising outcomes, a comprehensive meta-analysis affirming these benefits is lacking. This meta-analysis aims to compare the clinical outcomes of HHR and Laparoscopic Hernia Repair (LHR) in the management of IVH.

METHODS

An exhaustive search of the literature was conducted, targeting publications in both English and Chinese that compare HHR and LHR up to March 31, 2023. The primary outcomes examined were operation time, blood loss, and intestinal injury. Secondary outcomes included rates of seroma, wound infection, post-operative acute/chronic pain, recurrence, and mesh bulging. The RevMan 5.0 software facilitated the statistical meta-analysis.

RESULTS

The final analysis incorporated data from 14 studies, encompassing a total of 1158 patients, with 555 undergoing HHR and 603 treated with LHR. Follow-up data, ranging from 12 to 88 months, were available in 12 out of the 14 identified studies. The HHR method was associated with a significantly lower risk of seroma (OR = 0.29, P = 0.0004), but a higher risk of wound infection (OR = 2.10, P = 0.04). No significant differences were observed between the two techniques regarding operation time, blood loss, intestinal injury, intestinal obstruction, post-operative pain, mesh bulging, and recurrence.

CONCLUSIONS

The HHR technique did not demonstrate a clear advantage over LHR in reducing surgical complications, apart from a lower incidence of postoperative seroma. Surgeons with substantial expertise may choose to avoid incidental conversion or intentional hybrid procedures. Further research is needed to clarify the optimal surgical approach for IVH.

Ventral Hernia Repair: Does Mesh Position Matter?

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

Ventral hernia repair with concurrent intra-abdominal surgery: Results from an eleven-year population-based cohort in Sweden

BACKGROUND

One remaining question in ventral hernia repair is whether to perform concurrent abdominal surgery or plan two-stage procedures. The aim was to explore the risk for reoperation and mortality due to surgical complication during index admission.

METHOD

Eleven-year data were retrieved from the National Patient Register and 68,058 primary surgical admissions were included, divided into minor and major hernia surgery and concurrent abdominal surgery. Results were evaluated by logistic regression analysis.

RESULTS

The risk for reoperation during index admission was higher for patients with concurrent surgery. Major hernia surgery and major concurrent surgery had an OR 37.9 compared to major hernia surgery only. Mortality rate within 30 days increased, OR 9.32. The combined risk for serious adverse event was accumulative.

CONCLUSION

These results stress the importance of critically evaluating needs for and planning of concurrent abdominal surgery during ventral hernia repair. Reoperation rate was a valid and useful outcome variable.

An obstetrician-gynecologist's review of hernias: risk factors, diagnosis, prevention, and repair

Management of obstetrical and gynecologic patients with hernias poses challenges to providers. Risks for hernia development include well-described factors that impair surgical wound healing and increase abdominal pressure. Among the diverse populations cared for by obstetricians and gynecologists, pregnant patients and those with gynecologic malignancies are at the highest risk for hernia formation. This article provides an overview of the existing literature, with a focus on patients cared for by obstetrician-gynecologists and commonly encountered preoperative and intraoperative scenarios. We highlight scenarios when a hernia repair is not commonly performed, including those of patients undergoing nonelective surgeries with known or suspected gynecologic cancers. Finally, we offer multidisciplinary recommendations on the timing of elective hernia repair with obstetrical and gynecologic procedures, with attention to the primary surgical procedure, the type of preexisting hernia, and patient characteristics.

Modifiable comorbidities impact on ventral hernia recurrence following robotic abdominal wall reconstruction using resorbable biosynthetic mesh: 36-month follow-up

Background

There is an ongoing debate on the role of comorbidities in hernia outcomes, particularly with minimally invasive approaches. This study evaluated the impact of modifiable comorbidities (MCMs) on 36-month hernia recurrence rates after robotic transversus abdominis release (TAR) with resorbable biosynthetic mesh underlay for primary ventral hernia repair.

Methods

A review of medical records for patients who underwent the robotic TAR procedure between January 2015 and May 2022 performed by a single surgeon was conducted. Patients were separated into three groups: those with 0, 1, and 2+ MCMs, followed by a breakdown of comorbidity types and combinations of comorbidities. MCMs included obesity, diabetes, and tobacco use. The primary outcomes included hernia recurrence at 36 months and the time between surgery and recurrence.

Results

175 patients met the inclusion criteria, with a mean hernia diameter of 12.9 ± 5.4 cm and a mean BMI of 34 ± 8 kg/m2. 9.7 % of patients experienced hernia recurrence at 36-month follow-up. No significant difference in the recurrence rate and length of time between surgery and recurrence was observed between the groups (p = .265 and p = .283, respectively). No group, single comorbidity, or a combination of comorbidities was found to have significantly increased odds of recurrence at 36 months.

Conclusion

The presence of MCMs, either alone or in combination with another, did not significantly increase the odds of hernia recurrence at 36 months following ventral hernia repair using this approach. Future studies with larger sample sizes and multiple surgeons are needed to corroborate this data.

Key message

Modifiable comorbidities have previously been shown to increase the risk of hernia recurrence after ventral hernia repair. Our study found relatively low rates of hernia recurrence and no significantly increased odds of recurrence among different comorbid groups at 36-month follow-up following robotic transversus abdominis release with resorbable biosynthetic mesh underlay.

Laparoscopic treatment of ventral hernias: the Italian national guidelines

Primary and incisional ventral hernias are significant public health issues for their prevalence, variability of professional practices, and high costs associated with the treatment In 2019, the Board of Directors of the Italian Society for Endoscopic Surgery (SICE) promoted the development of new guidelines on the laparoscopic treatment of ventral hernias, according to the new national regulation. In 2022, the guideline was accepted by the government agency, and it was published, in Italian, on the SNLG website. Here, we report the adopted methodology and the guideline's recommendations, as established in its diffusion policy. This guideline is produced according to the methodology indicated by the SNGL and applying the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Fifteen recommendations were produced as a result of 4 PICO questions. The level of recommendation was conditional for 12 of them and conditional to moderate for one. This guideline's strengths include relying on an extensive systematic review of the literature and applying a rigorous GRADE method. It also has several limitations. The literature on the topic is continuously and rapidly evolving; our results are based on findings that need constant re-appraisal. It is focused only on minimally invasive techniques and cannot consider broader issues (e.g., diagnostics, indication for surgery, pre-habilitation).

Comparison of emergent laparoscopic and open repair of acutely incarcerated and strangulated hernias-short- and long-term results

BACKGROUND

Incarcerated and strangulated hernias are a common clinical presentation encompassing several challenges in acute care surgery. The role of laparoscopy is still controversial and the data is scarce. Laparoscopy enables better evaluation of the incarcerated organ and its viability. The use of mesh repair in these emergent operations is also a major concern. In this series we aimed to evaluate the safety and efficacy of laparoscopic emergent repairs of acutely incarcerated and strangulated hernias, and their long-term results, in comparison to the conventional open repairs.

METHODS

Retrospective review of prospectively collected data of all adult patients, between the ages of 18 and 89, who underwent emergent operation due to an incarcerated and strangulated hernia between November 2017 and December 2020.

RESULTS

During the study period, 89 patients underwent emergent operation due to incarcerated hernias-63 laparoscopic repair and 26 underwent an open repair. In the laparoscopic group (LG) 38 patients had a groin hernia and 25 had a ventral hernia, while in the open group (OG) the distribution was 12 and 14, respectively. When operated laparoscopically, all groin hernias but one were repaired in the TAPP approach and most ventral hernias were repaired using the IPOM + approach. During the peri-operative period there were 3 mortalities (1 in the LG). There were no significant differences between the groups in minor or major complications. Mean follow-up time in the LG was 27.9 months and 29.4 months in the OG. There was no significant difference in recurrence rates. Long-term results showed better outcome in the LG regarding pain at rest, difficulty doing exercise and local discomfort.

CONCLUSION

Laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach, with better short and long-term results compared to the open approach.

The efficacy of goal-directed recommendations in overcoming barriers to elective ventral hernia repair in older adults

BACKGROUND

Although ventral hernias are common in older adults and can impair quality of life, multiple barriers exist that preclude ventral hernia repair. The goal of this study was to determine if older adults with ventral hernias achieve surgeon-directed goals to progress to an elective ventral hernia repair.

METHODS

Patients ≥60 years evaluated for a ventral hernia in a specialty clinic from January 2018 to August 2021 were retrospectively reviewed. Nonoperative candidates with modifiable risk factors were included. Data collected included specific barriers to ventral hernia repair and recommendations to address these barriers for future ventral hernia repair eligibility. Patients lost to follow-up were contacted by phone.

RESULTS

In total, 559 patients were evaluated, with 182 (32.6%) deemed nonoperative candidates with modifiable risk factors (median age 68 years, body mass index 38.2). Surgeon-directed recommendations included weight loss (53.8%), comorbidity management by a medical specialist (44.0%), and smoking cessation (19.2%). Ultimately, 45/182 patients (24.7%) met preoperative goals and progressed to elective ventral hernia repair. Alternatively, 5 patients (2.7%) required urgent/emergency surgical intervention. Importantly, 106/182 patients (58.2%) did not return to clinic after initial consultation. Of those contacted (n = 62), 35.5% reported failure to achieve optimization goals. Initial body mass index ≥40 and surgeon-recommended weight loss were associated with lack of patient follow-up (P = .01, P = .02) and progression to elective ventral hernia repair (P = .009, P = .005).

CONCLUSION

Nearly one-third of older adults evaluated for ventral hernias were nonoperative candidates, most often due to obesity, and over half of these patients were lost to follow-up. An increase in structured support is needed for patients to achieve surgeon-specified preoperative goals.

Major complications and mortality after ventral hernia repair: an eleven-year Swedish nationwide cohort study

BACKGROUND AND AIMS

Ventral hernia repair is one of the most common surgical procedures performed worldwide. Despite the large volume, consensus is lacking regarding indications for repair or choice of surgical method used for reconstruction. The aim of this study was to explore the risk for major complications and mortality in ventral hernia repair using data from a nationwide patient register.

METHOD

Patient data of individuals over 18 years of age who had a ventral hernia procedure between 2004 and 2014 were retrieved from the Patient Register kept by the Swedish National Board of Health and Welfare. After exclusion of patients with concomitant bowel surgery, 45 676 primary surgical admissions were included. Procedures were dichotomised into laparoscopic and open surgery, and stratified for primary and incisional hernias.

RESULTS

A total of 45 676 admissions were analysed. The material comprised 36% (16 670) incisional hernias and 64% (29 006) primary hernias. Women had a higher risk for reoperation during index admission after primary hernia repair (OR 1.84 (1.29-2.62)). Forty-three patients died of complications within 30 days of index surgery. Patients aged 80 years and older had a 2.5 times higher risk for a complication leading to reoperation, and a 12-fold higher mortality risk than patients aged 70-79 years.

CONCLUSION

Age is the dominant mortality risk factor in ventral hernia repair. Laparoscopic surgery was associated with a lower risk for reoperation during index admission. Reoperation seems to be a valid outcome variable, while registration of complications is generally poor in this type of cohort.

Comparison of Surgical Treatment Results of Large Incisional Hernias

Introduction Incisional hernias are one of the most common complications after abdominal surgery. Surgical repairs of large incisional hernias have higher complications and recurrence rates compared to smaller incisional hernia repairs. For this reason, it is a more difficult and experience-requiring application for surgeons. In addition, there is no evidence-based consensus in the literature regarding the optimal surgical treatment of large incisional hernias. The aim of this study is to compare the results of the three most common surgical treatment methods used in a tertiary university hospital for the repair of large incisional hernias in terms of patients' characteristics, recurrence, and complication rates of the treatment methods. Methods Between 2014 and 2020, 366 patients with incisional hernias with facial defects larger than 10 cm in a tertiary medical faculty hospital located in eastern Turkey were analyzed. Patients were divided into three groups according to the surgical method used: open onlay prolene mesh (OPM) method, laparoscopic intraperitoneal sublay dual mesh (IPSDM) method, and open IPSDM method. Postoperative complications were divided into five groups as follows: wound complications, complications due to surgical procedures, medical complications, recurrences, and mortality. Treatment methods were compared according to the demographic characteristics of the patients and the postoperative complication rates. Results Of the patients, 141 were male and 225 were female, and the mean age was 58.0 ± 28 years. Of the patients, 81.9% were operated on with the open OPM, 10.9% with the laparoscopic IPSDM, and 7.1% with the open IPSDM. Wound complications occurred in 26.7% of patients, surgical complications in 3.2%, medical complications in 6.5%, recurrence in 9.2%, and mortality in 0.8% of patients. Total wound complications were significantly higher in the open OPM group (30%) (p = 0.009). Total surgery complications were significantly higher in the laparoscopic IPSDM group (15%) (p = 0.002). There was no significant difference between groups for medical complications (p = 0.540). Although no recurrence was observed in the open IPSDM group, no significant difference was observed between the groups (p = 0.099). There was no difference in mortality rates between the groups (p = 0.450). The overall complication rate was highest in the open OPM group (48.3%) and lowest in the open IPSDM group (27%) (p = 0.092). The operative time was found to be significantly shorter in open IPSDM (p < 0.001). The length of hospital stay was highest in the open OPM group and lowest in the open IPSDM group (p = 0.450). Conclusions Although hernia defect is greater in the open IPSDM compared to other methods, this method is more advantageous in terms of the complication rate associated with the surgical procedure, the overall complication rate, the duration of surgery, and the recurrence rate. Laparoscopic IPSDM is a more advantageous method in terms of the overall wound and medical complications.

Polypharmacy is predictive of postoperative complications in older adults undergoing ventral hernia repair

BACKGROUND

Ventral hernias are common in older adults, and may be repaired via a transversus abdominus release (TAR). Older adults undergoing surgery have unique age-related risk factors, including polypharmacy. Polypharmacy is highly prevalent in older adults and is associated with adverse postoperative outcomes. Our aim was to examine the prevalence and association of polypharmacy with clinical outcomes in older adults undergoing a TAR.

METHODS

Patients 60 years and older who underwent elective open or robotic bilateral TAR were included in the study. Average daily medications taken preoperatively was collected and stratified by tertiles. Baseline demographic data, peri- and postoperative outcomes, and 30-day outcomes were collected.

RESULTS

There were 132 total patients with an average age of 67.8 years. The number of daily medications ranged from 0 to 28, with an overall mean of 11.2 medications. Patients in tertile 1 took an average of 5.3 medications, tertile 2 10.5 medications, and tertile 3 17.9 medications. Patients in tertile 3 had more than double the rate of in-hospital complications (0.7) compared to tertiles 1 and 2 (0.3 and 0.3, respectively; p = 0.03). A greater number of daily medications was independently associated with postoperative delirium [odds ratio (OR) 1.2, 95% confidence interval (CI) 1.0-1.3], cardiac events (OR 1.2, 95% CI 1.0-1.3), ICU stay (OR 1.2, 95% CI 1.0-1.3), and discharge to a skilled nursing facility (SNF) (OR 1.2, 95% CI 1.0-1.5).

CONCLUSIONS

Polypharmacy was very common in older adults undergoing a TAR, and was associated with in-hospital complications, postoperative delirium, cardiac events, ICU stay, length of stay, and discharge to a SNF. Additional study is needed to assess if preoperative interventions to limit polypharmacy will improve outcomes for older adults undergoing a TAR.

Long-term Follow-up of Patients With Hernia Using the Hernia-Specific Quality-of-Life Mobile App: Feasibility Questionnaire Study

BACKGROUND

Hernia repair is one of the most common surgical procedures; however, the long-term outcomes are seldom reported due to incomplete follow-up.

OBJECTIVE

The aim of this study was to examine the use of a mobile app for the long-term follow-up of hernia recurrence, complication, and quality-of-life perception.

METHODS

A cloud-based corroborative system drove a mobile app with the HERQL (Hernia-Specific Quality-of-Life) questionnaire built in. Patients who underwent hernia repair were identified from medical records, and an invitation to participate in this study was sent through the post.

RESULTS

The response rate was 11.89% (311/2615) during the 1-year study period, whereas the recurrence rate was 1.0% (3/311). Causal relationships between symptomatic and functional domains of the HERQL questionnaire were indicated by satisfactory model fit indices and significant regression coefficients derived from structural equational modeling. Regarding patients' last hernia surgeries, 88.7% (276/311) of the patients reported them to be satisfactory or very satisfactory, 68.5% (213/311) of patients reported no discomfort, and 61.1% (190/311) of patients never experienced mesh foreign body sensation. Subgroup analysis for the most commonly used mesh repairs found that mesh plug repair inevitably resulted in worse symptoms and quality-of-life perception from the group with groin hernias.

CONCLUSIONS

The mobile app has the potential to enhance the quality of care for patients with hernia and facilitate outcomes research with more complete follow-up.

Ventral hernia repair with a hybrid laparoscopic technique

BACKGROUND

Ventral hernias are increasingly managed with minimally invasive laparoscopic surgery. Invasive open surgery is typically used for the repair of large-sized hernias (>10 cm diameter). The two methods are often considered mutually exclusive. We report a hybrid technique for repair of medium to large-sized hernias.

METHODS

Data was collected prospectively from 44 hernias repaired using the hybrid technique from 2012 to 2020. Operative data was examined and follow-up conducted by both clinical and phone review. As for surgical technique, laparoscopic access was established via a 5 mm optical port and two (or more) 5 mm ports were added under vision. Hernia contents were reduced and extraperitoneal fat excised around the defect. Hernias with diameters ranging from 5 to 10 cm were fixed using the hybrid technique. A small incision was made directly over the hernia and polyester mesh was placed intraabdominally before defect closure with a transfascial suture. Pneumoperitoneum was re-established and mesh fixation achieved using absorbable tacks and/or fixation sutures.

RESULTS

Of the 44 ventral hernias repaired with the hybrid technique, 43 were secondary hernias from incisional defects. Average hernia diameter was 6.6 cm. 86% of patients were discharged within the first 48 h. Four patients (9%) had recurrences during the study period. Minor complications occurred in 8 patients (18%): 3 (7%) had post-operative wound infection, 3 patients (7%) developed post-operative seroma. Two patients (5%) had clinically significant wound haematoma.

CONCLUSION

Laparoscopic hybrid ventral hernia repair can be safely performed by a combination of laparoscopic and open techniques, offering an alternative method in the management of medium-sized ventral hernias.

Assessment of Quality of Life After Ventral Hernia Repair: A Prospective Observational Study at a Tertiary Care Centre

Background

Ventral hernias are usually repaired by an open or laparoscopic approach. Quality of life after ventral hernia repair is a very important but often underestimated parameter. This prospective observational study was conducted to assess the quality of life and other related parameters after all types of ventral hernia repair, mainly between open and laparoscopic repairs. 

Objectives

This study aimed to determine the quality of life after ventral hernia repairs. We also analysed and compared various parameters such as outcomes and satisfaction, postoperative pain, and complications between laparoscopic and open ventral hernia repair. 

Methods

This was a hospital-based prospective observational study conducted from January 2020 to December 2021, which included a total of 70 patients with ventral hernias. Thirty-nine patients underwent open repair and 31 patients underwent laparoscopic repair. Demographic data and other data such as postoperative hospital stay, return to activity, postoperative pain, complications, and quality of life were collected and analysed.

Results

The distribution of different types of hernias observed in our study included 34% incisional hernias, 33% umbilical and paraumbilical hernias, and 33% epigastric hernias. The incidence of complications was significantly less in laparoscopic repair compared to open repair. Also, satisfaction at 1 month was significantly more in the laparoscopic group compared to the open group. However, there is no significant difference in the postoperative pain, postoperative hospital stay, return to activity, satisfaction at discharge, and quality of life at 1 month in both the laparoscopic and open repairs. 

Conclusion

Laparoscopic ventral hernia repairs are associated with lesser complications and higher satisfaction. The use of tackers and trans-fascial sutures can significantly increase postoperative pain in laparoscopic repair and is the major factor affecting the short-term quality of life in laparoscopic repairs. As there is no difference in postoperative pain, hospital stay, and return to activity, laparoscopic repairs should be preferred wherever possible in view of fewer complications and higher satisfaction. 

Randomized control trial evaluating the use of a shared decision-making aid for older ventral hernia patients in the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) Program

PURPOSE

Shared decision making (SDM) is ideally suited to abdominal wall surgery in older adults given the breadth of decision making required by the hernia surgeon and the impact on quality of life (QOL) by various treatment options. Given the paucity of literature surrounding SDM in hernia patients, the feasibility of a novel, formalized SDM aid/tool was evaluated in a pilot randomized trial.

METHODS

Patients 60 years or older with a diagnosed ventral hernia were prospectively randomized at an academic hernia center. In the experimental arm, a novel SDM tool, based on the SHARE Approach, guided the consultation. Previously validated SDM assessments and patient's hernia knowledge retention was measured.

RESULTS

Eighteen (18) patients were randomized (9 control and 9 experimental). Cohorts were well matched in age (p = 0.51), comorbidities (Charlson Comorbidity Score: p = 0.43) and frailty (mFI-11: p = 0.19; Risk Analysis Index: p = 0.33). Consultation time was 11 min longer in the experimental cohort (p < 0.01). There was a trend towards better Decisional Conflict Scores in the experimental group (p = 0.25) and the experimental cohort had improved post-visit retained hernia knowledge (p < 0.01). All patients in the experimental arm (100%) enjoyed working through the SDM aid/tool and felt it was a worthwhile exercise.

CONCLUSION

Incorporating a formalized SDM tool into a busy hernia surgical practice is feasible and well received by patients. In addition, early results suggest it improves retention of basic hernia knowledge and may reduce patient's decisional conflict. Next steps include condensing the SDM tool to enhance efficiency within the clinic and beginning a large, randomized control trial.

Geriatric assessment and medical preoperative screening (GrAMPS) program for older hernia patients

PURPOSE

The incidence of older adults undergoing inguinal and ventral hernia repairs is increasing. Older adults are disproportionately affected by age-related risk factors, which are often under-recognized and may adversely affect surgical outcomes. These age-related risk factors often termed "geriatric syndromes," include multimorbidity, frailty, cognitive impairment, depression, obesity, functional impairment, polypharmacy, and poor subjective health. The aim of this study was to identify the prevalence of age-related risk factors in older patients undergoing elective hernia repair.

METHODS

Patients aged 60 years or older with a planned elective surgical repair of a ventral or inguinal hernia were prospectively enrolled in a clinic. Subjects completed several validated screening tools for geriatric syndromes.

RESULTS

Seventy patients completed preoperative assessments (mean age: 68.5 years). In total, 24 (34.3%) screened positive for previously unrecognized objective cognitive impairment (Mini-Cog) and 33 (47.1%) for a subjective memory concern. Sixty patients (85.7%) met criteria for polypharmacy. Additionally, 48 (68.6%) screened positive for either pre-frailty (37, 52.9%) or frailty (11, 15.7%), and 66 (94.3%) had multimorbidity. Twenty-five (35.7%) patients self-rated their health as "poor" or "fair," and 18 (25.7%) patients endorsed some functional impairment.

CONCLUSIONS

There is a high prevalence of age-related risk factors in older patients undergoing elective hernia repair. Further, these factors are often unrecognized and underappreciated despite their potential to significantly impact informed consent and shared decision making. Additional study is required to define the impact of these age-related risk factors on surgical outcomes, which will inform preoperative risk assessment and optimization through modifiable risk reduction.

Chronological age does not predict postoperative outcomes following transversus abdominis release (TAR)

BACKGROUND

Transversus abdominis release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TAR is not a low risk operation, particularly in older adults who are disproportionately affected by multiple age-related risk factors. While past studies have suggested that age alone inconsistently predicts patient outcomes, data regarding age's effect on postoperative outcomes and wound complications following a TAR are lacking.

METHODS

Patients who underwent either an open or robotic bilateral TAR from 1/2018 to 9/2020 were eligible for the study. Patients were stratified by age groups (≥ 60 years vs. < 60 years and < 60, 60-70, and ≥ 70) and by both age and operative approach. The rates of key postoperative outcomes and wound morbidity were compared between the various cohorts.

RESULTS

A total of 300 patients were included: 165 patients were ≥ 60 and 135 patients were < 60. Cohorts stratified by age were well-matched for important hernia factors: defect size (p = 0.31), BMI ≥ 30 (p = 0.46), OR time (p = 0.25), percent open TAR (p = 0.42), diabetes (p = 0.45) and history of prior surgical site infection (p = 0.40). The older cohort had significantly higher rates of coronary artery disease, hypertension, and COPD. On univariate analysis, cohorts stratified by age had similar rates of key postoperative and wound complications including in-hospital complications (p = 0.62), length of stay (p = 0.47), readmissions (p = 0.66), and surgical site occurrences (p = 0.68). Additionally, cohorts stratified by both age and operative approach also had similar outcomes. Multivariate analysis showed that chronological age was not independently associated with surgical site occurrences (p = 0.22), readmissions (p = 0.99), in-hospital complications (p = 0.15), or severe complications (p = 0.79).

CONCLUSION

Open and robotic TARs can be safely performed in older adults and chronological age alone is a poor predictor of patient morbidity following TAR. Further investigation of alternative preoperative screening tools that do not rely solely on age are needed to better optimize surgical outcomes in older adults following TAR.

Are perioperative outcomes in cancer-related ventral incisional hernia repair worse than in the general population? An Abdominal Core Health Quality Collaborative (ACHQC) database study

PURPOSE

Patients with a history of cancer-related abdominal surgery undergoing incisional hernia repair (IHR) are highly heterogenous and increasingly prevalent. We explored whether cancer surgery should be considered an independent risk factor for worse IHR perioperative outcomes.

METHODS

Patients undergoing IHR between 2018 and 2020 were identified within the Abdominal Core Health Quality Collaborative (ACHQC). Regression models were used to assess associations between cancer operation history and 30 d surgical site occurrences-exclusive of infection (SSO-EIs), surgical site infections (SSIs), reoperations, time to recurrence, and quality of life (QoL) scores. Cancer cohort subgroup analysis was performed for operative approach and mesh location.

RESULTS

8019 patients who underwent IHR were identified in the ACHQC, 1321 of which had a history of cancer operation. Cancer cohort patients were more likely to be older, males with a higher ASA status and lower BMI, and have longer and wider hernias (p < 0.001). After adjusting for confounding, the cancer cohort was less likely to experience SSO-EIs (OR 0.74, 95% CI 0.59-0.94 p = 0.0092) and showed lower odds of SSIs, reoperations, and recurrence (SSI OR 0.7, 95% CI 0.47-1.05, p = 0.0542; reoperation OR 0.66, 95% CI 0.37-1.17, p = 0.1002; recurrence OR 0.8, 95% CI 0.63-1.02, p = 0.08). There was no difference in postoperative QoL scores between cohorts. There were also no differences in perioperative or QoL outcomes within the cancer cohort based on operative approach or mesh location.

CONCLUSION

These data show no evidence that history of cancer operation predisposes patients to worse incisional hernia repair perioperative or quality of life outcomes.

Safety and efficacy of absorbable and non-absorbable fixation systems for intraperitoneal mesh fixation: an experimental study in swine

PURPOSE

Choice of the best possible fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of the present study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation.

METHODS

Fourteen Landrace swine were utilized in the study. The experiment included two stages. Initially, four pieces of mesh (Ventralight ™ ST) sizing 10 × 5 cm were placed and fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. These defects were repaired primarily with absorbable suture before mesh implantation. Each mesh was anchored with a different tack device between Absorbatack™, Protack™, Capsure™, or Optifix™. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy via U-shaped incision to obtain the measurements for the outcome parameters. The primary endpoint of the study was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks.

RESULTS

Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Capsure™ tacks had higher peel strength when compared to Absorbatack™ (p = 0.028); Protack™ (p = 0.043); and Optifix™ (p = 0.009). No significant differences were noted regarding the extent of visceral adhesions (Friedman's test p value 0.854), the adhesion quality (Friedman's test p value 0.506), or the mesh shrinkage (Friedman's test p value = 0.827). Four out of the ten animals developed no adhesions at all 2 months after implantation.

CONCLUSION

Capsure™ fixation system provided higher peel strength that the other tested devices in our swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

Predictive factors of recurrence for laparoscopic repair of primary and incisional ventral hernias with single mesh from a multicenter study

Laparoscopic ventral hernia repair (LVHR) is a widely practiced treatment for primary (PH) and incisional (IH) hernias, with acceptable outcomes. Prevention of recurrence is crucial and still highly debated. Purpose of this study was to evaluate predictive factors of recurrence following LVHR with intraperitoneal onlay mesh with a single type of mesh for both PH and IH. A retrospective, multicentre study of data collected from patients who underwent LVHR for PH and IH with an intraperitoneal monofilament polypropylene mesh from January 2014 to December 2018 at 8 referral centers was conducted, and statistical analysis for risk factors of recurrence and post-operative outcomes was performed. A total of 1018 patients were collected, with 665 cases of IH (65.3%) and 353 of PH (34.7%). IH patients were older (p < 0.001), less frequently obese (p = 0.031), at higher ASA class (p < 0.001) and presented more frequently with large, swiss cheese type and border site defects (p < 0.001), compared to PH patients. Operative time and hospital stay were longer for IH (p < 0.001), but intraoperative and early post-operative complications and reinterventions were comparable. IH group presented at major risk of recurrence than PH (6.7% vs 0.9%, p < 0.001) and application of absorbable tacks resulted a significative predictive factor for recurrence increasing the risk by 2.94 (95% CI 1.18–7.31). LVHR with a light-weight polypropylene mesh has low intra- and post-operative complications and is appropriate for both IH and PH. Non absorbable tacks and mixed fixation system seem to be preferable to absorbable tacks alone.

Impact of type of minimally invasive approach on open conversions across ten common procedures in different specialties

BACKGROUND

Conversion rates during minimally invasive surgery are generally examined in the limited scope of a particular procedure. However, for a hospital or payor, the cumulative impact of conversions during commonly performed procedures could have a much larger negative effect than what is appreciated by individual surgeons. The aim of this study is to assess open conversion rates during minimally invasive surgery (MIS) across common procedures using laparoscopic/thoracoscopic (LAP/VATS) and robotic-assisted (RAS) approaches.

STUDY DESIGN

Retrospective cohort study using the Premier Database on patients who underwent common operations (hysterectomy, lobectomy, right colectomy, benign sigmoidectomy, low anterior resection, inguinal and ventral hernia repair, and partial nephrectomy) between January 2013 and September 2015. ICD-9 and CPT codes were used to define procedures, modality, and conversion. Propensity scores were calculated using patient, hospital, and surgeon characteristics. Propensity-score matched analysis was used to compare conversions between LAP/VATS and RAS for each procedure.

RESULTS

A total of 278,520 patients had MIS approaches of the ten operations. Conversion occurred in 5% of patients and was associated with a 1.77 day incremental increase in length of stay and $3441 incremental increase in cost. RAS was associated with a 58.5% lower rate of conversion to open surgery compared to LAP/VATS.

CONCLUSION

At a health system or payer level, conversion to open is detrimental not just for the patient and surgeon but also puts a significant strain on hospital resources. Use of RAS was associated with less than half of the conversion rate observed for LAP/VATS.

Systematic review and meta-analysis of risk factors for Mesh infection following Abdominal Wall Hernia Repair Surgery

BACKGROUND

Surgical Mesh Infection (SMI) after Abdominal Wall Hernia Repair (AWHR) represents a catastrophic complication. We performed a systematic review and meta-analysis to analyze the risk factors for SMI in the context of AWHR.

METHODS

PubMed, Embase, Scielo, and LILACS were searched without language or time restrictions from inception until June 2021. Articles evaluating the association between demographic, clinical, laboratory and surgical characteristics with SMI in AWHR were included.

RESULTS

23 studies were evaluated, comprising a total of 118,790 patients (98% males; mean age 56.5 years) with a mesh infection pooled prevalence of 4%. Significant risk factors for SMI were type 2 diabetes mellitus, obesity, smoking history, steroids use, ASA III/IV, laparotomy vs laparoscopy, emergency surgery, duration of surgery and onlay mesh position vs sublay. The quality of evidence was regarded as very low-moderate.

CONCLUSION

Several factors, highlighting sociodemographic characteristics, comorbidities, and the clinical scenario, may increase the risk of developing mesh infections in AWHR. The recognition and mitigation of these may significantly reduce mesh infection rates in this context.

Perioperative outcomes of the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) program pilot for older hernia patients: does chronological age predict outcomes?

BACKGROUND

The Geriatric Assessment and Medical Preoperative Screening (GrAMPS) program was an initial attempt to understand and to define the prevalence of age-related risk factors in older patients undergoing elective ventral hernia repair (VHR) or inguinal hernia repair (IHR). Preliminary analysis found significant rates of previously unrecognized objective cognitive dysfunction, multimorbidity and polypharmacy. We now examine whether chronological age as a sole risk factor can predict a patient's perioperative outcomes, and if traditional risk calculators that rely heavily on chronological age can accurately capture a patient's true risk.

METHODS

This was a retrospective secondary analysis of the previously reported GrAMPS trial enrolling patients 60 years and older with a planned elective repair of a ventral or inguinal hernia. The rates of key postoperative outcomes were compared between various cohorts stratified by chronological age. Previously validated risk screening calculators [Charlson Comorbidity Index (CCI), National Surgical Quality Improvement Program (NSQIP)] were compared between cohorts.

RESULTS

In total, 55 (78.6%) of the 70 patients enrolled in GrAMPS underwent operative intervention by May 2021, including 26 VHR and 29 IHRs. Cohorts stratified by chronological age had similar rates of key perioperative wound and age-related outcomes including readmissions, postoperative complications, non-home discharges, and length of stay. Additionally, while the commonly used risk calculators, CCI and NSQIP, consistently predicted worse outcomes for older hernia patients (stratified by both median age and age-tertiles), screening positive on these risk assessments were not actually predictive of a greater incidence of postoperative complications.

CONCLUSIONS

Chronological age does not accurately predict worse adverse postoperative complications in older hernia patients. Additionally, traditional risk screening calculators that rely heavily on age to risk stratify may not accurately capture a patient's true surgical risk. Surgeons should continue to explore nuanced patient risk assessments that more accurately capture age-related risk factors to better individualize perioperative risk.

Laparoscopic Treatment of Incisional and Ventral Hernia

Background and Objectives

Although several large studies regarding patients undergoing minimally invasive repair of incisional hernia are currently available, the results are not particularly reliable as they are based on heterogeneous groups, different surgical techniques, different mesh types, or with a too short follow period.

Methods

We conducted a retrospective observational trial, collecting data from patients who underwent laparoscopic repair of a primary abdominal wall or an incisional hernia using the laparoscopic Intraperitoneal Onlay Mesh technique and a single mesh type, i.e., a composite polyester mesh with a hydrophilic film (Parietex Composite^TM mesh - Medtronic, Minneapolis, MN - USA). All patients signed an informed consent.

Results

One thousand seven hundred seventy-seven patients were enrolled. The median surgery time was 50 minutes and the median length of hospital stay was 2 days. Intraoperative complications occurred in 12 patients (0.7%), while early postoperative surgical complications occurred in 115 (6.5%); during follow-up, bulging mesh was diagnosed in 4.5% of cases and hernia recurred in 4.3% of patients. An overlap equal or greater than 4 cm resulted as a significant protective factor, while the use of absorbable fixing devices was a risk factor for recurrence (odds ration: 9.06, p < 0.001, 95% confidence interval: 4.19 - 19.57).

Conclusions

Minimally invasive treatment of primary and postincisional abdominal wall hernias is a safe, effective, and reproducible procedure. An overlap equal or greater than 4 cm, the use of nonabsorbable fixing devices and a postoperative care and follow-up regime are crucial in order to obtain good results and low recurrence rates.

Robotic Incisional Hernia Repair After Robotic-assisted Radical Prostatectomy (RARP): A 3-port Approach

BACKGROUND/AIM

Incisional hernia is a complication that occurs occasionally, and surgical intervention is required to prevent more severe sequela. While there are several options for management, robotic-assisted incisional repair has not been well discussed yet. We herein report a case series of 10 patients who underwent robotic-assisted incisional hernia repair (RIHR) after robotic-assisted radical prostatectomy (RARP). The aim of the study was to examine the feasibility of incisional hernia repair with da Vinci® robotics.

PATIENTS AND METHODS

We recruited patients from a group of 2,000 consecutive patients who underwent RARP from December, 2005 to June, 2020 by a single surgeon. Patient characteristics included age, body mass index (BMI), PSA level, pathology Gleason score, and pathology TNM staging. The variants regarding the patients' incisional hernia included incisional hernia occurrence time after RARP, defect size, operation time, console time, blood loss, and follow-up time after the herniation occurrence. Furthermore, we established a defect size of 3x2 cm² as the cutoff value for using mesh reinforcement or not.

RESULTS

The mean defect area was 27.7 cm², and the average operative time was 114.8 min, with a mean console time of 87 min. Blood loss was 32.5 ml, and the hospital stay for all patients was 3 days without complications. The mean follow-up period was 29.5 months, with no recurrence.

CONCLUSION

RIHR is a feasible surgical method that is not inferior to the traditional open or laparoscopic repair. Furthermore, RIHR can possibly lessen the burden of both the surgeon and patient.

Incidence and risk factors for incisional hernia and recurrence: Retrospective analysis of the French national database

AIM

The aim of this work was to determine the rate of incisional hernia (IH) repair and risk factors for IH repair after laparotomy.

METHOD

This population-based study used data extracted from the French Programme de Médicalisation des Systèmes d'Informations (PMSI) database. All patients who had undergone a laparotomy in 2010, their hospital visits from 2010 to 2015 and patients who underwent a first IH repair in 2013 were included. Previously identified risk factors included age, gender, high blood pressure (HBP), obesity, diabetes and chronic obstructive pulmonary disease (COPD).

RESULTS

Among the 431 619 patients who underwent a laparotomy in 2010, 5% underwent IH repair between 2010 and 2015. A high-risk list of the most frequent surgical procedures (>100) with a significant risk of IH repair (>10% at 5 years) was established and included 71 863 patients (17%; 65 procedures). The overall IH repair rate from this list was 17%. Gastrointestinal (GI) surgery represented 89% of procedures, with the majority of patients (72%) undergoing lower GI tract surgery. The IH repair rate was 56% at 1 year and 79% at 2 years. Risk factors for IH repair included obesity (31% vs 15% without obesity, p  < 0.001), COPD (20% vs 16% without COPD), HBP (19% vs 15% without HBP) and diabetes (19% vs 16% without diabetes). Obesity was the main risk factor for recurrence after IH repair (19% vs 13%, p < 0.001).

CONCLUSION

From the PMSI database, the real rate of IH repair after laparotomy was 5%, increasing to 17% after digestive surgery. Obesity was the main risk factor, with an IH repair rate of 31% after digestive surgery. Because of the important medico-economic consequences, prevention of IH after laparotomy in high-risk patients should be considered.

Laparoscopic Versus Open Incisional Hernia Repair: Long-Term Follow-up Results of a Randomized Clinical Trial

PURPOSE

Long-term extension of a previous randomized controlled clinical trial comparing open (OVHR) vs. laparoscopic (LVHR) ventral hernia repair, assessing recurrence, reoperation, mesh-related complications and self-reported quality of life with 10 years of follow-up.

METHODS

Eighty-five patients were followed up to assess recurrence (main endpoint), reoperation, mesh complications and death, from the date of index until recurrence, death or study completion, whichever was first. Recurrence, reoperation rates and death were estimated by intention to treat. Mesh-related complications were only assessed in the LVHR group, excluding conversions (intraperitoneal onlay; n = 40). Quality of life, using the European Hernia Society Quality of Life score, was assessed in surviving non-reoperated patients (n = 47).

RESULTS

The incidence rates with 10 person-years of follow-up were 21.01% (CI 13.24-33.36) for recurrence, 11.92% (CI: 6.60-21.53) for reoperation and 24.88% (CI 16.81-36.82) for death. Sixty-two percent of recurrences occurred within the first 2 years of follow-up. No significant differences between arms were found in any of the outcomes analyzed. Incidence rate of intraperitoneal mesh complications with 10 person-years of follow-up was 6.15% (CI 1.99-19.09). The mean EuraHS-QoL score with 13.8 years of mean follow-up for living non-reoperated patients was 6.63 (CI 4.50-8.78) over 90 possible points with no significant differences between arms.

CONCLUSION

In incisional ventral hernias with wall defects up to 15 cm wide, laparoscopic repair seems to be as safe and effective as open techniques, with no long-term differences in recurrence and reoperation rates or global quality of life, although lack of statistical power does not allow definitive conclusions on equivalence between alternatives.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov (NCT04192838).

Age-Related Risk Factors in Ventral Hernia Repairs: A Review and Call to Action

BACKGROUND

As the population ages, the incidence of ventral hernias in older adults is increasing. Ventral hernia repairs (VHR) should not be considered low risk operations, particularly in older adults who are disproportionately affected by multiple age-related factors that can complicate surgery and adversely affect outcomes. Although age-related risk factors have been well established in other surgical fields, there is currently little data describing their impact on VHR.

METHODS

We performed a systematic review of the literature to identify studies that examine the effects of age-related risk factors on VHR outcomes. This was conducted using Cochrane Library, Embase, PubMed (Medline), and Google Scholar databases, all updated through June 2020. We selected relevant studies using the keywords, multimorbidity, comorbidities, polypharmacy, functional dependence, functional status, frailty, cognitive impairment, dementia, sarcopenia, and malnutrition. Primary outcomes include mortality and overall complications following VHR.

RESULTS

We summarize the evidence basis for the significance of age-related risk factors in elective surgery and discuss how these factors increase the risk of adverse outcomes following VHR. In particular, we explore the impact of the following risk factors: multimorbidity, polypharmacy, functional dependence, frailty, cognitive impairment, sarcopenia, and malnutrition. As opposed to chronological age itself, age-related risk factors are more clinically relevant in determining VHR outcomes.

CONCLUSIONS

Given the increasing complexity of VHR, addressing age-related risk factors pre-operatively has the potential to improve surgical outcomes in older adults. Preoperative risk assessment and individualized prehabilitation programs aimed at improving patient-centered outcomes may be particularly useful in this population.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results

INTRODUCTION

Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation.

AIM

To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach.

METHODS

A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported.

RESULTS

66 patients were included in the study. Median follow-up was 22 months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12 years, 30 kg/m², 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9 cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%).

CONCLUSION

eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.

Open versus laparoscopic incisional hernia repair: nationwide database study

Background

Although laparoscopic repair of incisional hernias decreases the incidence of wound complications compared with open repair, there has been rising concern related to intraperitoneal mesh placement. The aim of this study was to examine outcomes after open or laparoscopic elective incisional hernia mesh repair on a nationwide basis.

Methods

This study analysed merged data from the Danish Hernia Database and the National Patient Registry on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence among patients who underwent primary repair of an incisional hernia between 2007 and 2018.

Results

A total of 3090 (57.5 per cent) and 2288 (42.5 per cent) patients had surgery by a laparoscopic and open approach respectively. The defect was closed in 865 of 3090 laparoscopic procedures (28.0 per cent). The median follow-up time was 4.0 (i.q.r. 1.8–6.8) years. Rates of readmission (502 of 3090 (16.2 per cent) versus 442 of 2288 (19.3 per cent); P = 0.003) and reoperation for complication (216 of 3090 (7.0 per cent) versus 288 of 2288 (12.5 per cent); P < 0.001) were significantly lower for laparoscopic than open repairs. Reoperation for bowel obstruction or bowel resection was twice as common after laparoscopic repair compared with open repair (20 of 3090 (0.6 per cent) versus 6 of 2288 (0.3 per cent); P = 0.044). Patients were significantly less likely to undergo repair of recurrence following laparoscopic compared with open repair of defect widths 2–6 cm (P = 0.002).

Conclusion

Laparoscopic intraperitoneal mesh repair for incisional hernia should still be considered for fascial defects between 2 and 6 cm, because of decreased rates of early complications and repair of hernia recurrence compared with open repair.

Ten-year trends in minimally invasive hernia repair: a NSQIP database review

BACKGROUND

Utilization of minimally invasive techniques for ventral and inguinal hernia repairs continues to rise. The purpose of this study was to provide updates on national utilization trends and wound complications of minimally invasive versus open ventral and inguinal hernia repairs.

METHODS

Data were accessed from the 2006 to 2017 National Surgical Quality Improvement Program database. All CPT codes that correlated to laparoscopic and open inguinal and ventral hernia repairs were queried. The total number of cases and wound complications, including superficial surgical site infection (SSI), deep SSI, organ space SSI, and wound dehiscence, was collected for each respective CPT code and compared for each year. IBM SPSS Statistics Software and Microsoft Excel were used to collect and analyze the data.

RESULTS

Between 2009 and 2017, the percentage of minimally invasive inguinal hernia repairs increased from 23.1 to 37.8%, whereas the percentage of minimally invasive ventral hernias only increased from 31.5 to 36.6%. Open inguinal hernia repairs had a wound complication rate ranging from 0.60 to 0.74%, which was double the rate of minimally invasive repairs (0.24 to 0.49%) for nearly each respective year. Minimally invasive ventral hernia repairs had total wound complication rates ranging from 0.91 to 1.37%, whereas open ventral hernias had the highest total wound complication rates ranging from 5.07 to 6.26%.

CONCLUSIONS

Over the last ten years, the utilization of minimally invasive inguinal and ventral hernia repair has increased by nearly two-fold. A larger proportion of this increase has been secondary to minimally invasive inguinal compared to ventral hernia repairs. Wound complications across all techniques remained stable or improved, and remained significantly less in the minimally invasive compared to open approaches. This study highlights the continued growth of minimally invasive techniques in hernia repair over the last decade.

Quality of Life Using the Carolinas Comfort Scale for Laparoscopic Incisional Hernia Repair: A 12-Year Experience in a Retrospective Observational Study

Background: Incisional hernias are a common complication of abdominal surgery (10%-35%) and are notorious for recurrence. Laparoscopic incisional hernia repair (LIHR) was first performed in 1991 and is reported to have lower recurrence rates. Few studies to date have assessed quality of life (QoL) resulting from a repair. The purpose of this observational study was to present a 12-year experience performing LIHR, with a focus on the impact on QoL. Methods: All adult patients undergoing elective LIHR performed by a single surgeon, whether primary or recurrent, were included in the study. The data collection was performed prospectively between 2007 and 2019 to include demographic details, intraoperative findings and postoperative short- and longterm outcomes. We used the Carolinas Comfort Scale (CCS) to assess QoL following surgery. Results: Ninety-seven patients were included in the study. Patients had a median age of 57 years, body mass index of 32 kg/m², 35% were male and 88% were American Society of Anesthesiologists (ASA) class I or II. The duration of surgery was 90 minutes*. Nineteen percent of patients had complications during or after surgery; 1 (1%) had recurrence. length of stay in hospital was 1* (0-12) days and long-term follow-up period was 42* (2-140) months after surgery. Time of return to daily activities was 14* (1-365) days. Eighty-six percent of patients rated their experience undergoing LIHR as "Excellent" or "Good". Regarding QoL after surgery, scores on the CCS indicated that 82% of patients had minimal or no discomfort following surgery, and only 1% had significant discomfort. *Presented as median. Conclusions: The technique for LIHR displayed in this study is safe and effective. There was an acceptable rate of complications, with a low recurrence rate. Patients were highly satisfied and had a good QoL after the procedure. Research Registry ID Number: researchregistry6056.

Endoscopic preaponeurotic access for complex ventral hernia repair with sublay mesh and bilateral anterior component separation: A case report

Introduction

Minimally invasive techniques are now routine in complex abdominal wall defects repair. Although laparoscopy allows to reduce post-operative pain, promoting a more rapid recovery and shortening hospital stay, it is associated with risk of bowel injury and adhesions development, when intraperitoneal mesh is placed. We report the case of a patient affected by large recurrent incisional hernia, treated with a new hybrid endoscopic approach.

Presentation of case

Patient treated with the novel approach is a 53-year-old male, BMI 27, smoker, with epigastric recurrence of incisional hernia and prosthetic fistula. An endoscopic preaponeurotic subcutaneous access was used. Repair with sublay mesh, bilateral anterior component separation and muscular reinsertions was conducted. Three months after surgery, no signs of recurrence were observed and complete functional recovery had been achieved.

Discussion

The new technique adopted benefits from all the advantages of minimally invasive surgery, allowing to avoid risks associated with laparoscopic access. Bilateral anterior component separation with muscular reinsertions is the key for tension-free suture.

Conclusion

To our knowledge, this is the first time that a complex recurrent incisional hernia is repaired with the hybrid technique aforementioned. The approach used is certainly technically challenging, thus requiring a team skilled in the use of laparoscopy. Good outcomes reported are a further demonstration that minimally invasive surgery can be a valid alternative to traditional open techniques for large abdominal wall defects repair.

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Minimally invasive surgical techniques are commonly used in complex ventral hernia repair.

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Laparoscopy is effective but it is associated with the risk of bowel injury and adhesions development.

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Component separation allows tension-free suture in presence of large hernia defects.

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A hybrid approach with endoscopic preaponeurotic access can be used to treat complex cases.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Recurrent incisional hernia repair: surgical outcomes in correlation with body-mass index

BACKGROUND

Hernia recurrence rates after incisional hernia repair vary between 8.7 and 32%, depending on multiple factors such as patient characteristics, the use of meshes, surgical technique and the degree of experience of the treating surgeon. Recurrent hernias are considered complex wall hernias, and 20% of all incisional hernia repairs involve a recurrent hernia. The aim of this study was to investigate the outcomes after recurrent incisional hernia repair, in association with surgical technique and body-mass index (BMI).

METHODS

All patients who had incisional hernia repair between 2013 and 2018 were included. Primary outcome was rate of recurrent incisional hernia after initial hernia repair. Secondary outcomes were complication rate and recurrence rate in association with BMI.

RESULTS

A number of 269 patients were included, of which 75 patients (27.9%) with a recurrent incisional hernia. Recurrent hernia repair was performed in 49 patients, 83.7% underwent open repair. Complication rate for recurrent hernia repair was higher than for the initial incisional hernia repair. Of the 49 patients with recurrent hernia repair, patients with a BMI above 30 had higher complication and recurrence rates compared to patients with BMI below 30. Especially infectious complications were more common in patients with a higher BMI: 23.1% vs. 0% wound infections.

CONCLUSION

The results from this study show that complication and recurrence rates are increased after recurrent incisional hernia repair, which are further increased by obesity. Only a limited amount of literature is available on this topic, further larger multicenter studies are necessary, until then a patient-specific surgical approach based on the surgeon's expertise is recommended.