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Amaral PHF, Macret JZ, Dias ERM, Carvalho JPV, Pivetta LGA, Ribeiro HB, Franciss MY, Silva RA, Malheiros CA, Roll S. Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure. Hernia 2024; 28:53-61. [PMID: 37563426 DOI: 10.1007/s10029-023-02848-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/23/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. METHOD A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. RESULTS Imaging post-BTA revealed hernia width reduction of 1.9 cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1 cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. CONCLUSION BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.
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Affiliation(s)
- P H F Amaral
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil.
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil.
| | - J Z Macret
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - E R M Dias
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - J P V Carvalho
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - L G A Pivetta
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
| | - H B Ribeiro
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - M Y Franciss
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - R A Silva
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - C A Malheiros
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
| | - S Roll
- Santa Casa de Sao Paulo - Abdominal Wall Surgery Unit, Rua Cesário Mota Júnior, 112 - Vila Buarque, São Paulo, SP, Brazil
- Hospital Alemão Oswaldo Cruz, Hernia Center, São Paulo, SP, Brazil
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Amato G, Agrusa A, Buscemi S, Di Buono G, Calò PG, Vella R, Romano G, Barletta G, Cassata G, Cicero L, Romano G. Tentacle Mesh for Fixation-Free Spigelian Hernia Repair: Mini-Invasive Approach Granting Broad Defect Overlap. J Clin Med 2023; 12:3866. [PMID: 37373561 DOI: 10.3390/jcm12123866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/10/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Compared to other types of abdominal protrusions, Spigelian hernias are not very common. In prosthetic repair of abdominal protrusions, mesh fixation and defect overlap are an open issue, as they are a source of complications. A newly developed tentacle-shaped mesh has been used to ensure a fixation-free repair with a broader defect overlap in the repair of abdominal hernias. This study describes the long-term results of a fixation-free repair of Spigelian hernias carried out with a tentacle mesh. METHODS A proprietary mesh composed of a central body with integrated radiating arms was used for repairing Spigelian hernias in 54 patients. The implant was positioned in preperitoneal sublay, and the straps were delivered across the abdominal musculature with a needle passer, and then, after fascia closure, cut short in the subcutaneous layer. RESULTS The friction of the straps passing through the abdominal wall served to hold the mesh in place, guaranteeing a wide overlap over the defect without fixation. In a long-term follow-up of 6 to 84 months (mean 64 months), a very low rate of complications occurred, but no recurrence was reported. CONCLUSIONS The tentacle strap system of the prosthesis allowed for an easy, fast and safe fixation-free placement granting a wide overlap, avoiding intraoperative complications. Greatly reduced pain and a negligible amount of postoperative complications characterized the postoperative outcome.
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Affiliation(s)
- Giuseppe Amato
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
| | - Antonino Agrusa
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
| | - Salvatore Buscemi
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
| | - Giuseppe Di Buono
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
| | - Roberta Vella
- Postgraduate School of General Surgery, University of Palermo, 90127 Palermo, Italy
| | - Giorgio Romano
- Postgraduate School of General Surgery, University of Palermo, 90127 Palermo, Italy
| | - Gabriele Barletta
- Postgraduate School of General Surgery, University of Palermo, 90127 Palermo, Italy
| | - Giovanni Cassata
- CEMERIT (Centro Meridionale Ricerca e Training), IZSS, 90129 Palermo, Italy
| | - Luca Cicero
- CEMERIT (Centro Meridionale Ricerca e Training), IZSS, 90129 Palermo, Italy
| | - Giorgio Romano
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
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Niu EF, Kozak GM, McAuliffe PB, Amro C, Bascone C, Honig SE, Elsamaloty LH, Hao M, Broach RB, Kovach SJ, Fischer JP. Preoperative Botulinum Toxin for Abdominal Wall Reconstruction in Massive Hernia Defects-A Propensity-Matched Analysis. Ann Plast Surg 2023; 90:S543-S546. [PMID: 37399480 DOI: 10.1097/sap.0000000000003488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
PURPOSE Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction. METHODS This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05. RESULTS Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661). CONCLUSIONS In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.
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Affiliation(s)
- Ellen F Niu
- From the Division of Plastic Surgery, Department of Surgery
| | | | | | - Chris Amro
- From the Division of Plastic Surgery, Department of Surgery
| | - Corey Bascone
- From the Division of Plastic Surgery, Department of Surgery
| | | | - Lina H Elsamaloty
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Meng Hao
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Robyn B Broach
- From the Division of Plastic Surgery, Department of Surgery
| | | | - John P Fischer
- From the Division of Plastic Surgery, Department of Surgery
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4
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A review of recent developments of polypropylene surgical mesh for hernia repair. OPENNANO 2022. [DOI: 10.1016/j.onano.2022.100046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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5
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Laparoscopic management of ventral hernia repair using intraperitoneal synthetic mesh: A 10-year retrospective observational study. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Effects of Botulinum Toxin A on an Incisional Hernia Reconstruction in a Rat Model. Plast Reconstr Surg 2021; 147:1331-1341. [PMID: 33974596 DOI: 10.1097/prs.0000000000007986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although the effects of botulinum toxin A on hernia reconstruction have been consistently reported, few studies provide objective evidence. The authors aimed to compare the effects of chemical component separation with those of mechanical component separation, and with a combination of chemical and mechanical component separation, in a rat hernia model. METHODS Rats were divided into four groups: 1, control; 2, chemical component separation; 3, mechanical component separation; and 4, chemical and mechanical component separation. Four weeks after hernia induction, botulinum toxin A was injected into groups 2 and 4. Hernia repair was performed 2 weeks after chemical component separation when mechanical component separation was performed in groups 3 and 4. Pretreatment and posttreatment defect sizes, traction forces, intraabdominal pressure, and hernia recurrences were analyzed. RESULTS The defect size was significantly decreased in groups 2 and 4 after chemical component separation. The traction force was significantly smaller in groups 2 and 3 compared with the control group, and the effects of chemical and mechanical component separation were additive. The mean intraabdominal pressure was 16.83 mmHg in group 1, 10.67 mmHg in group 2, 10.17 mmHg in group 3, and 9.67 mmHg in group 4, thus showing significant reductions following chemical and mechanical component separation. Recurrence was observed in all six animals (100 percent) in groups 1 and 3, but in only one of six (17 percent) in groups 2 and 4. CONCLUSIONS Preoperative botulinum toxin A significantly reduces hernia size (by 30 percent) and the traction force required to medialize the rectus abdominis. After hernia repair, chemical component separation decreases the intraabdominal pressure to a similar degree as mechanical component separation, but only chemical component separation appears to reduce hernia recurrence.
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Guerra O. Noncrosslinked Porcine-derived Acellular Dermal Matrix for Single-stage Complex Abdominal Wall Herniorrhaphy after Removal of Infected Synthetic Mesh: A Retrospective Review. Am Surg 2020. [DOI: 10.1177/000313481408000521] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This retrospective case review details the use of noncrosslinked intact porcine-derived acellular dermal matrix (PADM) for incisional herniorrhaphy in patients with infected synthetic mesh. A consecutive series of adult patients underwent single-stage ventral herniorrhaphy involving removal of infected synthetic mesh and repair with PADM by a single surgeon (2009 to 2011). Comorbidities, repair procedures, postoperative complications, and hernia recurrence were noted. Of the 13 patients (mean age, 60 years; female, n = 8), seven (54%) were obese and six (46%) had chronic obstructive pulmonary disease/emphysema. Most synthetic mesh infections were polymicrobial (n = 7, 46%) or associated with Staphylococcus aureus (n = 4 [31%]). Six patients had undergone two or more previous repairs. With single-stage herniorrhaphy using PADM, primary fascial closure was achieved in 11 patients; bridged closure was required in two patients. Mean (median) duration of hospital stay was 12 (7) days and follow-up was 23 (22) months. There was one wound infection (drained surgically, PADM remained in place) and one seroma (resolved without intervention) observed during follow-up. There were two hernia recurrences, both in patients who received PADM as bridged repair. PADM yielded favorable outcomes when used for single-stage repair of complex ventral hernias in high-risk patients with infected synthetic mesh.
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Affiliation(s)
- Omar Guerra
- From Suburban Surgical Associates, St. Louis, Missouri
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8
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Parker SG, Halligan S, Liang MK, Muysoms FE, Adrales GL, Boutall A, de Beaux AC, Dietz UA, Divino CM, Hawn MT, Heniford TB, Hong JP, Ibrahim N, Itani KMF, Jorgensen LN, Montgomery A, Morales-Conde S, Renard Y, Sanders DL, Smart NJ, Torkington JJ, Windsor ACJ. International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair. Br J Surg 2019; 107:209-217. [PMID: 31875954 DOI: 10.1002/bjs.11400] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/25/2019] [Accepted: 09/18/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. METHODS A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. RESULTS Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. CONCLUSION Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.
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Affiliation(s)
- S G Parker
- Abdominal Wall Unit, University College London Hospital, London, UK
| | - S Halligan
- UCL Centre for Medical Imaging, London, UK
| | - M K Liang
- Department of Surgery, McGovern Medical Center, University of Texas Health Science Center, Houston, Texas, USA
| | - F E Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | - G L Adrales
- Division of Minimally Invasive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - A Boutall
- Colorectal Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - A C de Beaux
- Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - U A Dietz
- Department of Visceral, Vascular and Thoracic Surgery, Kantonal Hospital of Olten, Olten, Switzerland
| | - C M Divino
- Department of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, USA
| | - M T Hawn
- Department of Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - T B Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - J P Hong
- Department of Plastic Surgery, Asan Medical Centre, University of Ulsan, Seoul, South Korea
| | - N Ibrahim
- Department of General Surgery, Macquarie University Hospital, Macquarie University, Sydney, New South Wales, Australia
| | - K M F Itani
- Department of General Surgery, Veterans Affairs Boston Health Care System, Boston and Harvard Universities, West Roxbury, Massachusetts, USA
| | - L N Jorgensen
- Digestive Disease Centre, Bispebjerg University Hospital, Copenhagen, Denmark
| | - A Montgomery
- Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden
| | - S Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital 'Virgen del Rocio', Seville, Spain
| | - Y Renard
- Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims Cedex, France
| | - D L Sanders
- Department of General and Upper Gastrointestinal Surgery, North Devon District Hospital, Barnstaple, UK
| | - N J Smart
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Exeter, UK
| | - J J Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - A C J Windsor
- Abdominal Wall Unit, University College London Hospital, London, UK
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Boukovalas S, Sisk G, Selber JC. Erratum: Addendum: Abdominal Wall Reconstruction: An Integrated Approach. Semin Plast Surg 2019; 32:199-202. [PMID: 31329738 DOI: 10.1055/s-0038-1673696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
[This corrects the article DOI: 10.1055/s-0038-1667062.].
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Affiliation(s)
- Stefanos Boukovalas
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Geoffrey Sisk
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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10
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Selective muscle botulinum toxin A component paralysis in complex ventral hernia repair. Hernia 2019; 24:287-293. [DOI: 10.1007/s10029-019-01939-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
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Suh H, Magdy M, Perera S. Evaluation of mesh fixation in laparoscopic ventral hernia repair. ANZ J Surg 2018; 89:772-774. [PMID: 30062725 DOI: 10.1111/ans.14283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 10/02/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Hyerim Suh
- Department of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Magdy
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
| | - Shevy Perera
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia.,Department of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
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Abstract
Abdominal wall reconstruction is a rapidly evolving area of surgical interest. Due to the increase in prevalence and size of ventral hernias and the high recurrence rates, the academic community has become motivated to find the best reconstruction techniques. Whilst interrogating the abdominal wall reconstruction literature, we discovered an inconsistency in hernia nomenclature that must be addressed. The terms used to describe the anatomical planes of mesh implantation ‘inlay’, ‘sublay’ and ‘underlay’ are misinterpreted throughout. We describe the misinterpretation of these terms and give evidence of where it exists in the literature. We give three critical arguments of why these misinterpretations hinder advances in abdominal wall reconstruction research. The correct definitions of the anatomical planes, and their respective terms, are described and illustrated. Clearly defined nomenclature is required as academic surgeons strive to improve abdominal wall reconstruction outcomes and lower complication rates.
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13
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Patel R, Reid TH, Parker SG, Windsor A. Intraluminal mesh migration causing enteroenteric and enterocutaneous fistula: a case and discussion of the 'mesh problem'. BMJ Case Rep 2018; 2018:bcr-2017-223476. [PMID: 29666083 DOI: 10.1136/bcr-2017-223476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The use of synthetic mesh in the abdominal compartment has recently become a topic of debate as high profile public cases have called into question their safety. Several case reports have demonstrated significant complications due to intra-abdominal mesh. Furthermore, some studies have suggested that the rates of these severe complications are underestimated. We present the case of a patient who developed an enteroenteric and enterocutaenous fistulae, an abdominal wall collection and an intraperitoneal inflammatory mass from intraluminal migration of a synthetic mesh inserted during laparoscopic incisional hernia repair. We discuss the considerations and complications of using synthetic mesh for ventral hernia repair and discuss the scientific evidence behind the increasingly apparent 'mesh problem'.
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Affiliation(s)
- Reeya Patel
- General Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Thomas H Reid
- General Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sam G Parker
- General Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alistair Windsor
- General Surgery, University College London Hospitals NHS Foundation Trust, London, UK
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14
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Oma E, Jensen KK, Jorgensen LN. Increased risk of ventral hernia recurrence after pregnancy: A nationwide register-based study. Am J Surg 2017; 214:474-478. [DOI: 10.1016/j.amjsurg.2017.03.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 01/12/2017] [Accepted: 03/29/2017] [Indexed: 11/17/2022]
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15
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Weissler JM, Lanni MA, Tecce MG, Carney MJ, Shubinets V, Fischer JP. Chemical component separation: a systematic review and meta-analysis of botulinum toxin for management of ventral hernia. J Plast Surg Hand Surg 2017; 51:366-374. [PMID: 28277071 DOI: 10.1080/2000656x.2017.1285783] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ventral hernia represents a surgical challenge plagued by high morbidity and recurrence rates. Primary closure of challenging hernias is often prohibited by severe lateral retraction and tension of the abdominal wall musculature. Botulinum toxin injections have recently been identified as a potential pre-operative means to counteract abdominal wall tension, reduce hernia size, and facilitate fascial closure during hernia repair. This systematic review and meta-analysis reviews outcomes associated with botulinum toxin injections in the setting of ventral hernia, and demonstrates an opportunity to leverage this mainstream aesthetic product for use in abdominal wall reconstruction. METHODS A literature review was conducted according to PRISMA guidelines using MeSH terms 'ventral hernia', 'herniorrhaphy', 'hernia repair', and 'botulinum toxins'. Relevant studies reporting pre- and postinjection data were included. Outcomes of interest included changes in hernia defect width and lateral abdominal muscle length, recurrence, complications, and patient follow-up. Qualitative findings were also considered to help demonstrate valuable themes across the literature. RESULTS Of 133 results, 12 were included for qualitative review and three for quantitative analysis. Meta-analysis revealed significant hernia width reduction (mean = 5.79 cm; n = 29; p < 0.001) and lateral abdominal wall muscular lengthening (mean = 3.33 cm; n = 44; p < 0.001) following botulinum injections. Mean length of follow-up was 24.7 months (range = 9-49). CONCLUSIONS Botulinum toxin injections offer tremendous potential in ventral hernia management by reducing hernia width and lengthening abdominal wall muscles prior to repair. Although further studies are needed, there is a significant opportunity to bridge the knowledge gap in preoperative practice measures for ventral hernia risk reduction.
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Affiliation(s)
- Jason M Weissler
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Michael A Lanni
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Michael G Tecce
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Martin J Carney
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - Valeriy Shubinets
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
| | - John P Fischer
- a Division of Plastic Surgery, Department of Surgery , University of Pennsylvania , Philadelphia , PA , USA
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Romano G, Calò PG, Erdas E, Medas F, Gordini L, Podda F, Amato G. Fixation-free incisional hernia repair in the elderly: our experience with a tentacle-shaped implant. Aging Clin Exp Res 2017; 29:173-177. [PMID: 27837460 DOI: 10.1007/s40520-016-0651-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/12/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Incisional hernia in aged patients represents a challenge even for experienced surgeons. Besides increased risk of complications due to comorbidities, mesh fixation and assuring a sufficient mesh overlap of the defect are the main issues in carrying out the repair. AIMS In order to assure broader coverage of the abdominal wall and a tension- and fixation-free repair, a specifically designed prosthesis was developed for the surgical treatment of incisional hernias. The results of a fixation-free incisional hernia repair carried out in elderly patients using a tentacle-shaped implant are reported herewith. METHODS A tentacle-shaped flat mesh with a large central body and integrated arms was used to repair incisional hernia in 23 elderly patients. The mesh was placed fixation-free and secured in place through the friction exerted by the tentacles. All tentacle straps were positioned with a special passer needle. Implant placement was preperitoneal in 18 patients and retromuscular sublay in five. RESULTS In a follow-up of 18 to 59 months (mean 36 months), four seromas occurred. Postoperative fast track helped avoid the typical complications affecting this patient subset. No infection, hematoma, chronic pain, mesh dislocation or recurrence have been reported to date. DISCUSSION The tentacle strap system allowed for reduced skin incision thus minimizing surgical trauma and ensuring easier and faster implant placement. CONCLUSION The tentacle arms of the implant ensured mesh stability and broad defect overlap. Besides a very low complication rate, none of the typical postoperative complications of aged patients occurred.
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Affiliation(s)
- Giorgio Romano
- Department of General Surgery and Emergency, University of Palermo, Palermo, Italy
| | - Pier Giorgio Calò
- Department of General Surgery, University of Cagliari, Cagliari, Italy
| | - Enrico Erdas
- Department of General Surgery, University of Cagliari, Cagliari, Italy
| | - Fabio Medas
- Department of General Surgery, University of Cagliari, Cagliari, Italy
| | - Luca Gordini
- Department of General Surgery, University of Cagliari, Cagliari, Italy
| | - Francesco Podda
- Department of General Surgery, University of Cagliari, Cagliari, Italy
| | - Giuseppe Amato
- Postgraduate School of General Surgery, University of Cagliari, Cagliari, Italy.
- , via M. Rapisardi 66, 90144, Palermo, Italy.
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Majumder A, Miller HJ, Patel P, Wu YV, Elliott HL, Novitsky YW. Evaluation of antibiotic pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction. Surg Endosc 2016; 31:2763-2770. [PMID: 27800587 DOI: 10.1007/s00464-016-5283-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite patient risk factors such as diabetes and obesity, contamination during surgery remains a significant cause of infections and subsequent wound morbidity. Pressurized pulse lavage (PPL) has been utilized as a method to reduce bacterial bioburden with promising results in many fields. Although existing methods of lavage have been utilized during abdominal operations, no studies have examined the use of PPL during complex hernia repair. METHODS Patients undergoing abdominal wall reconstruction (AWR) in clean-contaminated or contaminated fields with antibiotic PPL, from January 2012 to May 2013, were prospectively evaluated. Primary outcome measures studied were conversion of retrorectus space culture from positive to negative after PPL and 30-day surgical site infection (SSI) rate. RESULTS A total of 56 patients underwent AWR, with 44 patients (78.6 %) having clean-contaminated fields and 12 patients (21.4 %) having contaminated ones. Twenty-two patients (39.3 %) had positive pre-PPL cultures, 18 of which (81.8 %) converted to negative cultures after PPL. Eleven patients (19.6 %) developed SSIs. Those with persistently positive cultures after PPL had the highest rate of SSI, where two out of four patients (50.0 %) developed an SSI. Contrastingly, only 5 of 18 patients (27.8 %) who converted from a positive to negative culture after PPL developed an SSI. CONCLUSION Our findings demonstrate that antibiotic PPL is an effective method to reduce bacterial bioburden during AWR in clean-contaminated and contaminated fields. While complete conversion and eradication of SSI were not achieved, we believe that PPL may be a useful adjunct to standard operative asepsis in preventing prosthetic contamination during contaminated AWR.
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Affiliation(s)
- Arnab Majumder
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Heidi J Miller
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Parita Patel
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Yuhsin V Wu
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Heidi L Elliott
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Yuri W Novitsky
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Van Besien J, Vindevoghel K, Sommeling C. Central mesh failure after laparoscopic IPOM procedure. Acta Chir Belg 2016; 116:313-315. [PMID: 27426656 DOI: 10.1080/00015458.2016.1159427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Central mesh failure after laparoscopic repair of a ventral hernia is a rare finding. We present a case of a 42-year-old man with clear umbilical hernia recurrence 4 years after IPOM procedure with an oxidized cellulose composite polypropylene mesh, using the double crown technique. Laparoscopy showed that a segment of small intestine herniated through a central defect in the prosthesis. A primary repair of the umbilical hernia recurrence was performed through a small transverse infraumbilical incision suturing both the fascia and mesh with interrupted non-resorbable monofilament sutures. A plausible explanation for this type of recurrence might be that the center of the mesh was further torn after an initial (micro) trauma induced by the tackers used for fixation.
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Affiliation(s)
| | - Koen Vindevoghel
- Department of General Surgery, OLV van Lourdes, Waregem, Belgium
| | - Casper Sommeling
- Department of General Surgery, OLV van Lourdes, Waregem, Belgium
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19
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Tran D, Podwojewski F, Beillas P, Ottenio M, Voirin D, Turquier F, Mitton D. Abdominal wall muscle elasticity and abdomen local stiffness on healthy volunteers during various physiological activities. J Mech Behav Biomed Mater 2016; 60:451-459. [DOI: 10.1016/j.jmbbm.2016.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/19/2016] [Accepted: 03/03/2016] [Indexed: 10/22/2022]
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20
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Recurrent umbilical or epigastric hernia during and after pregnancy: A nationwide cohort study. Surgery 2016; 159:1677-1683. [PMID: 26857642 DOI: 10.1016/j.surg.2015.12.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/10/2015] [Accepted: 12/26/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Umbilical and epigastric (umb/epi) hernia repairs are performed commonly in fertile female patients. Recent studies suggest mesh repair to be superior to suture repair; however, evidence is lacking concerning the optimal treatment of umb/epi hernias in female patients who might wish future pregnancies. The aim of this study was to compare the cumulative recurrence rate after mesh versus suture repair of umb/epi hernia in female patients subsequently becoming pregnant. METHODS This retrospective nationwide cohort study included female patients who underwent primary umb/epi hernia repair and subsequently became pregnant between 2007 and 2013. The follow-up began at first day of pregnancy and ended May 2015. Data were obtained from the Danish Ventral Hernia Database, Medical Birth Registry, and National Patient Registry. Patients with recurrence before pregnancy were excluded. RESULTS In total, 224 patients were analyzed. The median follow-up was 3.8 years (range 0.1-8.1). The cumulative recurrence rate was 16.3% after mesh repair and 10.9% after suture repair, P = .299. Univariate Cox regression analysis (mesh repair hazard ratio 1.63, 95% confidence interval 0.71-3.72, P = .249) and multivariate analysis adjusted for body mass index and hernia defect size (mesh repair hazard ratio 2.77, confidence interval 0.98-7.85, P = .055) likewise showed no significant difference in the risk of recurrence when we compared mesh and suture repair. CONCLUSION Contrary to findings in the general operative patient, mesh repair was not associated with a lesser risk of recurrence compared with suture repair for treatment of umb/epi hernia in female patients with subsequent pregnancy.
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Garcia A, Baldoni A. Complex ventral hernia repair with a human acellular dermal matrix and component separation: A case series. Ann Med Surg (Lond) 2015; 4:271-8. [PMID: 26288732 PMCID: PMC4539183 DOI: 10.1016/j.amsu.2015.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 06/30/2015] [Accepted: 07/06/2015] [Indexed: 11/15/2022] Open
Abstract
We present a case series of 19 patients requiring complex abdominal hernia repairs. Patients presented with challenging clinical histories with 95% having multiple significant comorbidities including overweight or obesity (84%), hypertension (53%), diabetes (42%), cancer (26%), and pulmonary disease (16%). The majority of patients (68%) had prior abdominal infections and 53% had at least one failed prior hernia repair. Upon examination, fascial defects averaged 282 cm2. Anterior and posterior component separation was performed with placement of a human acellular dermal mesh. Midline abdominal closure under minimal tension was achieved primarily in all cases. Post-operative complications included 2 adverse events (11%) – one pulmonary embolism and one post-operative hemorrhage requiring transfusion; 6 wound-related complications (32%), 1 seroma (5%) and 1 patient with post-operative ileus (5%). Operative intervention was not required in any of the cases and most patients made an uneventful recovery. Increased patient age and longer OR time were independently predictive of early post-operative complications. At a median 2-year follow-up, three patients had a documented hernia recurrence (16%) and one patient was deceased due to unrelated causes. Conclusion Patients at high risk for post-operative events due to comorbidities, prior abdominal infection and failed mesh repairs do well following component separation reinforced with a human bioprosthetic mesh. Anticipated post-operative complications were managed conservatively and at a median 2-year follow-up, a low rate of hernia recurrence was observed with this approach. Intraperitoneal placement of acellular dermal matrix using component separation. Acceptable recurrence rates of 16% at 2 years of follow up. Correlation in age and complication chances. Retrorectus technique possibly the best surgical technique for hernia repair.
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Affiliation(s)
- Alvaro Garcia
- General Surgery and Abdominal Wall Reconstruction Center of South Florida, 17900 NW 5th St., Suite 201, Pembroke Pines, FL 33029, USA
| | - Anthony Baldoni
- General Surgery and Abdominal Wall Reconstruction Center of South Florida, 17900 NW 5th St., Suite 201, Pembroke Pines, FL 33029, USA
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22
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Panaro F, Matos-Azevedo AM, Fatas JA, Marin J, Navarro F, Zaragoza-Fernandez C. Endoscopic and histological evaluations of a newly designed inguinal hernia mesh implant: Experimental studies on porcine animal model and human cadaver. Ann Med Surg (Lond) 2015; 4:172-8. [PMID: 27158482 PMCID: PMC4846821 DOI: 10.1016/j.amsu.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/05/2015] [Accepted: 04/15/2015] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Conventional prostheses used for inguinal hernia repair are static and passive. This feasibility-study shows the features of a new 3D tension-free prosthesis in an experimental model. METHODS This study was divided into two-phases: 1) aimed to test the physics intrinsic features and the anatomical adaptability of a new 3D designed mesh, and 2) aimed to evaluate the inflammatory reaction associated with different materials used. On phase-1 implantations were performed in pigs. During the first trial phase, the prostheses were also implanted on human cadavers. On phase-2, implantation was carried out on large swine. Follow-up was of 60-days, after which the animals were anaesthetized for laparoscopic assessment, and for sample collection of mesh implantation site for histological analysis. RESULTS All animals showed good 3D mesh tolerance, and the follow-up period was uneventful. The laparoscopy showed no inflammatory lesions on the internal surface of the peritoneum. Macroscopic observation of implantation site revealed some local fibrosis and reorganization of tissue, no signs of infection, and no changes on original implant positioning. Histological analysis on phase-1 showed in most sample segments the deferent duct maintaining its central position and surrounded by vascular and nervous structures. On phase-2 differences in inflammatory lesion score could be found between subjects. CONCLUSIONS This new 3D mesh can be placed appropriately and from this preliminary animal study no untoward complications were noted over a 60 day period.
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Affiliation(s)
- Fabrizio Panaro
- Department of General and Liver Transplant Surgery, University of Montpellier, Hôpital Saint Eloi, 80 Avenue Augustin Fliche, 34295, Montpellier-Cedex 5, France
| | - Ana Maria Matos-Azevedo
- Laparoscopy Unit-Minimally Invasive Surgery, Centre Jesús Usón, Carretera N-521, 10071, Cáceres, Spain
| | - José Antonio Fatas
- Department of General Surgery, Hospital Royo Villanova, Avenida San Gregorio 30, 50015, Zaragoza, Spain
| | - Juan Marin
- Department of General Surgery, Valme University Hospital, Crta Cádiz s/n, 41014, Sevilla, Spain
| | - Francis Navarro
- Department of General and Liver Transplant Surgery, University of Montpellier, Hôpital Saint Eloi, 80 Avenue Augustin Fliche, 34295, Montpellier-Cedex 5, France
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Vranckx J, Stoel A, Segers K, Nanhekhan LL. Dynamic reconstruction of complex abdominal wall defects with the pedicled innervated vastus lateralis and anterolateral thigh PIVA flap. J Plast Reconstr Aesthet Surg 2015; 68:837-45. [DOI: 10.1016/j.bjps.2015.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/19/2015] [Accepted: 03/05/2015] [Indexed: 11/27/2022]
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Bolzon S, Vagliasindi A, Zanzi F, Negri M, Guerrini GP, Rossi C, Soliani P. Abdominal wall desmoid tumors: A proposal for US-guided resection. Int J Surg Case Rep 2015; 9:19-22. [PMID: 25706804 PMCID: PMC4392329 DOI: 10.1016/j.ijscr.2015.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/30/2015] [Accepted: 02/07/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Desmoid tumors (DTs) is a benign tumor with high tendency to infiltrative evolution and recurrence. Nowadays, in abdominal localization, the standard approach is surgery with R0 condition. The need to repair post-surgical wide wall defect requires conservative technique to decrease the incidence of incisional hernia and to obtain better quality of life (QoL). METHODS We perform an abdominal wall desmoid resection using ultrasound guide. This technique ensures to spare a wide wall area and to obtain a multilayer reconstruction minimizing postoperative risk. This approach allows good oncological results and better managing abdominal wall post-resection defect. RESULTS We use US guided surgery to get radical approach and wall tissue spare that allows us a multilayer reconstruction minimizing post-operative complications. No recurrences were observed in one year follow up period. CONCLUSION Our experience represents first step to consider ultrasound mediated technique usefull to optimize wall resection surgery and to minimize following complications.
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Affiliation(s)
- Stefano Bolzon
- Department of General and Urgent Surgery, "Santa Maria delle Croci" Hospital, Viale Randi 5, 48121 Ravenna, Italy.
| | - Alessio Vagliasindi
- Department of General and Urgent Surgery, "Santa Maria delle Croci" Hospital, Viale Randi 5, 48121 Ravenna, Italy
| | - Federico Zanzi
- Department of General and Urgent Surgery, "Santa Maria delle Croci" Hospital, Viale Randi 5, 48121 Ravenna, Italy
| | - Marco Negri
- Department of General and Urgent Surgery, "Santa Maria delle Croci" Hospital, Viale Randi 5, 48121 Ravenna, Italy
| | - Gian Piero Guerrini
- Department of General and Urgent Surgery, "Santa Maria delle Croci" Hospital, Viale Randi 5, 48121 Ravenna, Italy
| | - Camilla Rossi
- Department of General Surgery, Ferrara University, Arcispedale Sant'Anna, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Paolo Soliani
- Department of General and Urgent Surgery, "Santa Maria delle Croci" Hospital, Viale Randi 5, 48121 Ravenna, Italy
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Clinically relevant mechanical testing of hernia graft constructs. J Mech Behav Biomed Mater 2015; 41:177-88. [DOI: 10.1016/j.jmbbm.2014.10.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/15/2014] [Accepted: 10/19/2014] [Indexed: 12/28/2022]
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Zihni AM, Cavallo JA, Thompson DM, Chowdhury NH, Frisella MM, Matthews BD, Deeken CR. Evaluation of absorbable mesh fixation devices at various deployment angles. Surg Endosc 2014; 29:1605-13. [PMID: 25294536 DOI: 10.1007/s00464-014-3850-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/25/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hernia repair failure may occur due to suboptimal mesh fixation by mechanical constructs before mesh integration. Construct design and acute penetration angle may alter mesh-tissue fixation strength. We compared acute fixation strengths of absorbable fixation devices at various deployment angles, directions of loading, and construct orientations. METHODS Porcine abdominal walls were sectioned. Constructs were deployed at 30°, 45°, 60°, and 90° angles to fix mesh to the tissue specimens. Lap-shear testing was performed in upward, downward, and lateral directions in relation to the abdominal wall cranial-caudal axis to evaluate fixation. Absorbatack™ (AT), SorbaFix™ (SF), and SecureStrap™ in vertical (SSV) and horizontal (SSH) orientations in relation to the abdominal wall cranial-caudal axis were tested. Ten tests were performed for each combination of device, angle, and loading direction. Failure types and strength data were recorded. ANOVA with Tukey-Kramer adjustments for multiple comparisons and χ (2) tests were performed as appropriate (p < 0.05 considered significant). RESULTS At 30°, SSH and SSV had greater fixation strengths (12.95, 12.98 N, respectively) than SF (5.70 N; p = 0.0057, p = 0.0053, respectively). At 45°, mean fixation strength of SSH was significantly greater than SF (18.14, 11.40 N; p = 0.0002). No differences in strength were identified at 60° or 90°. No differences in strength were noted between SSV and SSH with different directions of loading. No differences were noted between SS and AT at any angle. Immediate failure was associated with SF (p < 0.0001) and the 30° tacking angle (p < 0.01). CONCLUSIONS Mesh-tissue fixation was stronger at acute deployment angles with SS compared to SF constructs. The 30° angle and the SF device were associated with increased immediate failures. Varying construct and loading direction did not generate statistically significant differences in the fixation strength of absorbable fixation devices in this study.
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Affiliation(s)
- Ahmed M Zihni
- Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St. Louis, MO, 63110, USA
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Alicuben ET, DeMeester SR. Onlay ventral hernia repairs using porcine non-cross-linked dermal biologic mesh. Hernia 2014; 18:705-12. [PMID: 23400527 PMCID: PMC4177570 DOI: 10.1007/s10029-013-1054-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 01/28/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Ventral hernias are common and repair with mesh has been shown to reduce recurrence. However, synthetic mesh is associated with a risk of infection. Biologic mesh is an alternative that may be less susceptible to infection. Typically, the sublay position is preferred for mesh placement but this technique takes longer and has not been shown to have a lower recurrence rate than an onlay mesh. The aim of this study was to evaluate the outcome of complex ventral hernia repair using a porcine non-cross-linked biologic mesh onlay. METHODS A retrospective chart review was performed of all patients that had a ventral hernia repair with biologic mesh from January 2009 to March 2012. The operative procedure in all patients was an open repair with primary fascial closure (if possible) with or without external oblique component separation and porcine biologic mesh onlay. RESULTS There were 22 patients that had a ventral hernia repair, 19 primary and 3 recurrent. The majority were men, had hernia grade 3 or 4, and developed the hernia after an esophagectomy or gastrectomy for cancer. All but one had primary closure with a porcine biologic mesh onlay. One patient was bridged for loss of domain. A bilateral external oblique component separation was added in 16 patients (73 %). The median hospital stay was 7 days. There were two superficial wound infections, one with exposed mesh, but no patient required mesh removal. A seroma requiring intervention developed in 6 patients (27 %) and resolved with pig-tail drainage. At a median follow-up of 7 months, there has been no hernia recurrence apart from the patient that was bridged. CONCLUSIONS Porcine non-cross-linked biologic mesh overlay has excellent short-term results in patients at increased risk for mesh infection. No patient required mesh removal, and there have been no recurrent hernias in patients with primary fascial closure. Biologic bridging is not effective for long-term abdominal wall reconstruction.
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Affiliation(s)
- E. T. Alicuben
- Department of Surgery, Keck School of Medicine, The University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033 USA
| | - S. R. DeMeester
- Department of Surgery, Keck School of Medicine, The University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033 USA
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Assessing complications and cost-utilization in ventral hernia repair utilizing biologic mesh in a bridged underlay technique. Am J Surg 2014; 209:695-702. [PMID: 25305799 DOI: 10.1016/j.amjsurg.2014.04.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 04/01/2014] [Accepted: 04/17/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND The inability to reapproximate fascia in complex ventral hernia (CVH) repair remains challenging. Single-stage bridging reconstructions have been reported, however, with high rates of recurrence and wound complications. We describe a single-surgeon experience with bridging biologic CVH repair. METHODS We reviewed 37 patients undergoing CVH repair with bridging biologic mesh by the senior author from January 1, 2007 to January 1, 2013. Surgical history and operative characteristics were analyzed for predictors of hernia recurrence and wound complications. RESULTS Average age was 53 ± 15 years, body mass index was 31.1 ± 8.1 kg/m(2), and history of prior repair in 18 patients. Common indications were trauma, intra-abdominal infection, and prior intra-abdominal surgery. Incidence of wound complications was 51.4%, most commonly wound breakdown and infection. With average follow-up of 13 months, recurrence rate was 18.9% at an average of 8.2 months postoperatively. Analysis demonstrated postoperative wound infection as the only predictor of recurrence (odds ratio = 22.1, P = .017). CONCLUSIONS Hernia recurrence rate was 18.9% with bridged biologic CVH repairs, strongly associated with postoperative wound infection. This suggests that patients with postoperative infections may benefit from closer surveillance and more aggressive wound management.
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Fujita T. Optimizing prosthetic technique for ventral hernia repair. J Am Coll Surg 2014; 218:1079-81. [PMID: 24745577 DOI: 10.1016/j.jamcollsurg.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 02/10/2014] [Indexed: 11/19/2022]
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Booth JH, Garvey PB, Baumann DP, Selber JC, Nguyen AT, Clemens MW, Liu J, Butler CE. Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 2013; 217:999-1009. [PMID: 24083910 DOI: 10.1016/j.jamcollsurg.2013.08.015] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many surgeons believe that primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR), yet others have reported acceptable outcomes when mesh is used to bridge the fascial edges. It has not been clearly shown how the outcomes for these techniques differ. We hypothesized that bridged repairs result in higher hernia recurrence rates than mesh-reinforced repairs that achieve fascial coaptation. STUDY DESIGN We retrospectively reviewed prospectively collected data from consecutive patients with 1 year or more of follow-up, who underwent midline AWR between 2000 and 2011 at a single center. We compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs. The primary outcomes measure was hernia recurrence. Multivariate logistic regression analysis was used to identify factors predictive of or protective for complications. RESULTS We included 222 patients (195 mesh-reinforced and 27 bridged repairs) with a mean follow-up of 31.1 ± 14.2 months. The bridged repairs were associated with a significantly higher risk of hernia recurrence (56% vs 8%; hazard ratio [HR] 9.5; p < 0.001) and a higher overall complication rate (74% vs 32%; odds ratio [OR] 3.9; p < 0.001). The interval to recurrence was more than 9 times shorter in the bridged group (HR 9.5; p < 0.001). Multivariate Cox proportional hazard regression analysis identified bridged repair and defect width > 15 cm to be independent predictors of hernia recurrence (HR 7.3; p < 0.001 and HR 2.5; p = 0.028, respectively). CONCLUSIONS Mesh-reinforced AWRs with primary fascial coaptation resulted in fewer hernia recurrences and fewer overall complications than bridged repairs. Surgeons should make every effort to achieve primary fascial coaptation to reduce complications.
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Affiliation(s)
- Justin H Booth
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Laparoscopic mechanical fixation devices: does firing angle matter? Surg Endosc 2013; 27:2076-81. [PMID: 23299138 DOI: 10.1007/s00464-012-2713-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 11/06/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND A variety of permanent and absorbable tacks are available for mesh fixation during laparoscopic hernia repairs. Although manufacturers recommend deploying tacks perpendicular to the tissue, achieving this can sometimes be challenging. This study aimed to analyze comparatively the effects of angled deployment among commonly used tacks. METHODS A piece of composite mesh was fixed to the peritoneal surface of a pig with a single tack fired at either a perpendicular (90°) or acute (30°) angle. A lap-shear test was performed to determine fixation strength. Two permanent tacks (a titanium spiral tack: Protack [PT]; and a hollow screw fastener: PermaFix [PF]) and three absorbable tackers (a solid screw: Absorbatack [AT]; a hollow screw fastener: SorbaFix [SF]; and a strap: SecurStrap [SS]) were challenged. A total of 16 samples were performed for each device at each angle. A nonabsorbable transfascial suture was used as a control condition. RESULTS Transabdominal sutures had the maximum acute tensile strength (ATS) (29.9 ± 5.5 N). Protack at both 90° and 30° performed significantly better than absorbable tacks (p < 0.01). No significant difference was found among absorbable tacks at 90°. When the same construct was compared at different angles, SS and SF performance was not affected (p = 0.07 and 0.2, respectively). In contrast, PT and AT had significantly reduced fixation strength (p = 0.003 and 0.004, respectively). However, PT fired at an acute angle had fixation equal to that of absorbable tacks fired perpendicularly. CONCLUSION Transabdominal sutures performed better than tacks in the acute setting. No absorbable fixation device demonstrated superior efficacy within its class. Spiral titanium tacks provided better fixation than absorbable tacks at both perpendicular and acute angles. Moreover, titanium spiral tacks deployed at 30° performed equal to or better than absorbable tacks fired perpendicularly to the tissue. It appears that spiral titanium tacks should be strongly considered for cases in which perpendicular tack deployment cannot be achieved.
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Abstract
Ventral hernias are a major surgical challenge with complications such as wound separations, infections, and recurrences contributing to patient morbidity. We describe a new adjunctive technique that may be helpful in repairing difficult ventral hernias: it involves using an appropriately chosen, redundant abdominal skin edge that is deepithelialized and used to reinforce the hernia repair. A series of 7 patients aged 23 to 84 years in whom the technique was used is presented. All patients had complete repair of their incisional ventral hernia defects without complications of infection, wound dehiscence, seroma formation, reoperation, or hernia recurrence. Furthermore, patients reported a subjective improvement in performing daily activities. Mean follow-up in this series was 19.2 months, with a range from 15.0 to 26.8 months. Advantages include the redistribution of mechanical tension, reinforcement of the midline site of greatest pressure, elimination of dead space, and staggering of suture lines to prevent direct external contamination of prosthetic material should wound dehiscence occur.
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Calaluce R, Davis JW, Bachman SL, Gubin MM, Brown JA, Magee JD, Loy TS, Ramshaw BJ, Atasoy U. Incisional hernia recurrence through genomic profiling: a pilot study. Hernia 2012; 17:193-202. [PMID: 22648066 PMCID: PMC3606513 DOI: 10.1007/s10029-012-0923-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 05/11/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE Although situational risk factors for incisional hernia formation are known, the methods used to determine who would be most susceptible to develop one are unreliable. We hypothesized that patients with recurrent incisional hernias may possess unique gene expression profiles. METHODS Skin and intact fascia were collected from 15 normal control (NC) patients with no hernia history and 18 patients presenting for recurrent incisional hernia (RH) repair. Microarray analysis was performed using whole genome microarray chips on NC (n = 8) and RH (n = 9). These samples were further investigated using a pathway-specific PCR array containing fibrosis-related genes. RESULTS Microarray data revealed distinct differences in the gene expression profiles between RH and NC patients. One hundred and sixty-seven genes in the skin and 7 genes in the fascia were differentially expressed, including 8 directly involved in collagen synthesis. In particular, GREMLIN1, or bone morphogenetic protein antagonist 1, was under expressed in skin (fold = 0.49, p < 10(-7), q = 0.0009) and fascia (fold = 0.23, p < 10(-4), q = 0.095) of RH patients compared with NC. The PCR array data supported previous reports of decreased collagen I/III ratios in skin of RH versus NC (mean = 1.51 ± 0.73 vs. mean = 2.26 ± 0.99; one-sided t test, p = 0.058). CONCLUSION To our knowledge, this is the first microarray-based analysis to show distinct gene expression profiles between the skin and fascia of RH and NC patients and the first report of an association between GREMLIN1 and incisional hernia formation. Our results suggest that gene expression profiles may act as surrogate markers that stratify patients into different groups at risk for hernia development prior to their initial surgery.
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Affiliation(s)
- R. Calaluce
- Department of Surgery, The University of Missouri Health Sciences Center, University of Missouri, One Hospital Drive, M610C, Columbia, MO 65212 USA
| | - J. W. Davis
- Department of Health Management and Informatics, The University of Missouri Health Sciences Center, University of Missouri, Columbia, MO USA
- Department of Statistics, University of Missouri, Columbia, MO USA
| | - S. L. Bachman
- Department of Surgery, The University of Missouri Health Sciences Center, University of Missouri, One Hospital Drive, M610C, Columbia, MO 65212 USA
| | - M. M. Gubin
- Department of Surgery, The University of Missouri Health Sciences Center, University of Missouri, One Hospital Drive, M610C, Columbia, MO 65212 USA
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, MO USA
| | - J. A. Brown
- Department of Surgery, The University of Missouri Health Sciences Center, University of Missouri, One Hospital Drive, M610C, Columbia, MO 65212 USA
| | - J. D. Magee
- Department of Surgery, The University of Missouri Health Sciences Center, University of Missouri, One Hospital Drive, M610C, Columbia, MO 65212 USA
| | - T. S. Loy
- Department of Pathology, Ross University, Roseau, Dominican Republic
| | - B. J. Ramshaw
- Transformative Care Institute, Daytona Beach, FL USA
| | - U. Atasoy
- Department of Surgery, The University of Missouri Health Sciences Center, University of Missouri, One Hospital Drive, M610C, Columbia, MO 65212 USA
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, MO USA
- Department of Child Health, University of Missouri, Columbia, MO USA
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Poghosyan T, Veyrie N, Corigliano N, Helmy N, Servajean S, Bouillot JL. Retromuscular Mesh Repair of Midline Incisional Hernia with Polyester Standard Mesh: Monocentric Experience of 261 Consecutive Patients with a 5-year Follow-up. World J Surg 2012; 36:782-90; discussion 791-2. [DOI: 10.1007/s00268-012-1443-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Garvey PB, Bailey CM, Baumann DP, Liu J, Butler CE. Violation of the rectus complex is not a contraindication to component separation for abdominal wall reconstruction. J Am Coll Surg 2011; 214:131-9. [PMID: 22169002 DOI: 10.1016/j.jamcollsurg.2011.10.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 10/22/2011] [Accepted: 10/31/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Component separation (CS) is an effective technique for reconstructing complex abdominal wall defects. Violation of the rectus abdominis complex is considered a contraindication for CS, but we hypothesized that patients have similar outcomes with or without rectus complex violation. STUDY DESIGN We retrospectively studied all consecutive patients who underwent CS for abdominal wall reconstruction during 8 years and compared outcomes of patients with and without rectus violation. Primary outcomes measures included complications and hernia recurrence. Logistic regression analysis identified potential associations between patient, defect, and reconstructive characteristics and surgical outcomes. RESULTS One hundred sixty-nine patients were included: 115 (68%) with and 54 (32%) without rectus violation. Mean follow-up was 21.3 ± 14.5 months. Patient and defect characteristics were similar, except for the rectus violation group having a higher body mass index. Overall complication rates were similar in the violation (24.3%) and nonviolation (24.0%) groups, as were the respective rates of recurrent hernia (7.8% vs 9.2%; p = 0.79), abdominal bulge (3.5% vs 5.6%; p = 0.71), skin dehiscence (20.0% vs 22.2%; p = 0.74), skin necrosis (6.1% vs 3.7%; p = 0.72), cellulitis (7.8% vs 9.2%; p = 0.75), and abscess (12.3% vs 9.2%; p = 0.58). Regression analysis demonstrated body mass index to be the only factor predictive of complications. CONCLUSIONS CS surgical outcomes were similar whether or not the rectus complex was violated. To our knowledge, this study is the first to evaluate the effects of rectus violation on surgical outcomes in CS patients. Surgeons should not routinely avoid CS when the rectus complex is violated.
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Affiliation(s)
- Patrick B Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Houston,TX 77030, USA
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Colon MJ, Telem DA, Chin E, Weber K, Divino CM, Nguyen SQ. Polyester composite versus PTFE in laparoscopic ventral hernia repair. JSLS 2011; 15:305-8. [PMID: 21985714 PMCID: PMC3183558 DOI: 10.4293/108680811x13125733356350] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study demonstrated no significant association between polyester composite and PTFE mesh and postoperative complications. Introduction: Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair. Methods: A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit. Results: Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P=NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS). Conclusion: Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.
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Affiliation(s)
- Modesto J Colon
- Department of Surgery, Division of General Surgery, The Mount Sinai Hospital, New York, New York, USA
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Chowbey PK, Sharma A, Mehrotra M, Khullar R, Soni V, Baijal M. Laparoscopic repair of ventral / incisional hernias. J Minim Access Surg 2011; 2:192-8. [PMID: 21187995 PMCID: PMC2999784 DOI: 10.4103/0972-9941.27737] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Despite its significant prevalence, there is little in the way of evidence-based guidelines regarding the timing and method of repair of incisional hernias. To add to the above is the formidable rate of recurrence that has been seen with conventional tissue repairs of these hernias. With introduction of different prosthetic materials and laparoscopic technique, it was hoped that an improvement in the recurrence and complication rates would be realized. The increasing application of the laparoscopic technique across the world indicates that these goals might indeed be achieved.
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Affiliation(s)
- Pradeep K Chowbey
- Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi - 110 060, India
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Amato G, Lo Monte AI, Cassata G, Damiano G, Romano G, Bussani R. A new prosthetic implant for inguinal hernia repair: its features in a porcine experimental model. Artif Organs 2011; 35:E181-90. [PMID: 21752035 DOI: 10.1111/j.1525-1594.2011.01272.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Even after more than 100 years of inguinal hernia repair, the rate of complications and recurrence remains unacceptably high. In the last decades, few effective advances in surgical technique and materials have been made. The authors see them as minor adjustments in the shape and materials of the prosthetic implants. Still, the underlying genesis of inguinal hernia remains undefined. Based upon this, it seems the surgical repair of inguinal protrusions cannot be based upon the pathogenesis because the etiology to date has not been addressed. Most hernia repairs are performed with some degree of point fixation (sutures/tacks) to stop the mesh from migrating and creating high recurrence rates. This should be a priority for our considerations, as fixating mesh puts it in stark contrast to the physiology and dynamics of the myotendineal structures of the groin. Following years of surgical practice, implant fixation, mesh shrinkage, and poor quality of tissue ingrowth still represent an unresolved issue in modern hernia repair. Conventional prosthetics used for inguinal hernia repair are static and passive. They do not move in harmony with the dynamic elements of the groin structure and, as a result, induce the ingrowth of thin scar plates or shrinking regressive tissue that colonizes the implants. The authors strongly believe that these characteristics may be a contributing factor for recurrences and patient discomfort. Other complications are reported in the literature to be a direct result of fixation of the implants, such as bleeding, nerve entrapment, hematoma, pain, discomfort, and testicular complications. To improve results by respecting the physiology and kinetics of the inguinal region, we felt that a new type of prosthesis should be designed that induces a more structured tissue ingrowth similar to the natural biologic components of the abdominal wall. This prosthetic device was specifically designed to be placed with no point fixation. This was achieved by using inherent radial recoil, vertical buffering, friction, and delivering the device in a constrained state. A secondary benefit of this "dynamic" design is that the implant moves in a three-dimensional way in unison with the movements of the myotendineal structures of the groin. The results appear to show that the three-dimensional structure not only acts as a suitable scaffold for a full thickness ingrowth of a tissue barrier but also seems to induce an ordered, supple, elastic tissue, which allows for neorevascularization and neoneural growth. The outcomes indicate a reduced impact of fibrotic shrinkage on the implant/scar tissue when compared with shrinkage of polypropylene meshes reported in the literature. This pilot study shows the features of such an implant in a porcine experimental model.
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Affiliation(s)
- Giuseppe Amato
- Department of General Surgery, Urgency, and Organ Transplantation, University of Palermo, Italy.
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Silvestre AC, de Mathia GB, Fagundes DJ, Medeiros LR, Rosa MI. Shrinkage evaluation of heavyweight and lightweight polypropylene meshes in inguinal hernia repair: a randomized controlled trial. Hernia 2011; 15:629-34. [PMID: 21748479 DOI: 10.1007/s10029-011-0853-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 06/24/2011] [Indexed: 02/01/2023]
Affiliation(s)
- A C Silvestre
- Laboratory of Epidemiology and National Institute for Translational Medicine, University do Extremo Sul Catarinense, Rua Cruz e Souza, 510, Bairro Pio Correa-CEP, Criciúma, SC 88811-550, Brazil
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New mesh shape and improved implantation procedure to simplify and standardize open ventral hernia repair: a preliminary report. Hernia 2011; 15:659-65. [DOI: 10.1007/s10029-011-0842-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 06/10/2011] [Indexed: 10/18/2022]
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Vannelli A, Battaglia L, Rampa M, Boati P, Putortì A, Pelleriti D, Fedele F, Leo E. Wall defects after abdominoperineal resection: A modified tension-free technique. TUMORI JOURNAL 2011; 97:323-7. [DOI: 10.1177/030089161109700311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The treatment of wall defects after abdominoperineal resection has yet to be defined. In this study we report the outcome of a modified prosthetic technique for the treatment of combined large incisional and parastomal hernia performed after abdominoperineal resection. Material and methods Between January 2005 and July 2008, 21 consecutive patients who underwent abdominoperineal resection for low rectal cancer received surgical repair for large incisional hernias with a modified mesh technique consisting of a tension-free attachment of the prosthetic material to the posterior sheath of the rectus abdominis muscle. The surgical outcome was assessed mainly as the recurrence rate of abdominal hernia and postoperative complications. Results Among the 21 patients we reported two minor complications: partial necrosis of the skin flap (4.8%) and a seroma (4.8%). One major complication occurred: extensive necrosis of the skin flap (4.8%). We reported one death due to stroke 20 days after surgery. The mean postoperative hospital stay was 6.1 days (SD, 2.3). Conclusions This study encourages the use of a tension-free modified prosthetic technique for the repair of combined wall defects after abdominoperineal resection. The technique does not lead to an increase in the incidence of complications, offering a considerable advantage to the patient.
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Affiliation(s)
- Alberto Vannelli
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
| | - Luigi Battaglia
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
| | - Mario Rampa
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
| | - Paolo Boati
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
| | - Antonella Putortì
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
| | - Daniela Pelleriti
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
| | - Fabienne Fedele
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
| | - Ermanno Leo
- Division of General Surgery B, Fondazione IRCCS “Istituto Nazionale dei Tumori”, Milan, Italy
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Carbonell Tatay F, García Pastor P, Bueno Lledó J, Saurí Ortiz M, Bonafé Diana S, Iserte Hernández J, Sastre Olamendi F. [Subxiphoid incisional hernia treatment: a technique using a double mesh adjusted to the defect]. Cir Esp 2011; 89:370-8. [PMID: 21524734 DOI: 10.1016/j.ciresp.2011.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 03/04/2011] [Accepted: 03/05/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Subxiphoid incisional hernia has characteristics that differentiate it from the rest and make it a distinctive entity. The fact that it has its sac very near the rib cage and sternum determines the pressure in the margins. The repair, by open or by laparoscopic approach, has not demonstrated good results despite the generalised use of a prosthesis. They are uncommon, and have a significant comorbidity in patients (severe heart diseases, transplants, immunosuppressed), after surgery of the hepato-bilio-pancreatic area with transverse incisions, or very high mid-laparotomies for gastro-oesophageal surgery. MATERIAL AND METHODS A new technique has been developed in our Unit, based on a double mesh and adapted to the anatomical and physiological characteristics of the region. The series consisted of 35 consecutive patients operated on between 2004 and 2010, following an agreed surgical and management protocol. RESULTS There were no significant complications -the most frequent (17.4%) was a seroma- except one case of a wound infection due to skin ischaemia in one patient who had had multiple operations and a transplant. During the post-surgical follow up to the present (between 4 and 80 months), there has been no recurrence of the incisional hernia and no significant local discomfort has been reported. CONCLUSIONS The «adjusted double mesh» technique achieved good results in our hands, from the surgical point of view (reproducibility, recurrence), and for the patient, with minimal discomfort and recovery of quality of life.
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Affiliation(s)
- Fernando Carbonell Tatay
- Unidad de Cirugía de Pared Abdominal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Fe, Valencia, España.
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Khandelwal RG, Bibyan M, Reddy PK. Transfascial suture hernia: a rare form of recurrence after laparoscopic ventral hernia repair. J Laparoendosc Adv Surg Tech A 2010; 20:753-5. [PMID: 20874415 DOI: 10.1089/lap.2010.0314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Laparoscopic repair of ventral or incisional hernia is among the most commonly performed minimally invasive procedures. Different modes of recurrence have been reported in literature, including missed defects, mesh migration, mesh infection, etc. Transfascial suture fixation in addition to tackers is an established method to prevent recurrence due to mesh migration. We report possibly the third case of recurrent ventral hernia with multiple defects at transfascial suture sites of previous laparoscopic ventral hernia mesh repair. The patient was treated by laparoscopy with a large intraperitoneal PROCEED mesh, covering the new hernia defects and older mesh.
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Barzana D, Johnson K, Clancy TV, Hope WW. Hernia recurrence through a composite mesh secondary to transfascial suture holes. Hernia 2010; 16:219-21. [PMID: 20835907 DOI: 10.1007/s10029-010-0728-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 08/26/2010] [Indexed: 11/26/2022]
Abstract
Laparoscopic ventral hernia repair is an accepted method for incisional hernia repair. Although techniques vary, transfascial suturing of the mesh to the abdominal wall has been proposed as a viable way to fixate the mesh and reduce recurrence rates. We report a 54-year-old woman who had previously undergone a laparoscopic ventral hernia repair following a laparoscopic tubal ligation using a Composix mesh. The patient presented with a symptomatic hernia recurrence. The computed tomography scan showed a periumbilical hernia containing fat. The patient underwent diagnostic laparoscopy and lysis of adhesions. During the lysis of adhesions, a recurrence through the previously placed composite mesh was encountered where holes had been made by the previously placed transfascial sutures. The hernia was reduced, mesh was removed, and an ePTFE mesh was used to repair the hernia. The mechanism of recurrence appeared to be improperly placed transfascial sutures; overly large bites of mesh caused excessive tension and ultimately a hole in the mesh. Hernia recurrence due to mesh or transfascial suture failure is rarely reported and most often caused by inadequate fixation. Our case highlights the need for meticulous placement of transfascial sutures and demonstrates a mechanism of recurrence due to inadequate placement.
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Affiliation(s)
- D Barzana
- Department of Surgery, New Hanover Regional Medical Center, South East Area Health Education Center, Wilmington, NC 28401, USA
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Prosthetic strap system for simplified ventral hernia repair: results of a porcine experimental model. Hernia 2010; 14:389-95. [PMID: 20333423 DOI: 10.1007/s10029-010-0650-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/05/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Aiming to achieve a simplified ventral hernia repair, a proprietary oval-shaped mesh was experimentally tested in a porcine model. The mesh is structured with a large central body and radiating straps. The friction of the straps passing through the tissues are hypothesized to be adequate to maintain the position of the mesh during tissue ingrowth, avoiding classic point fixation while ensuring a wide coverage of the abdomen. METHODS The mesh, having six radial straps, was placed using a sublay preperitoneal technique in four pigs. All straps were passed laterally through the abdominal wall and exteriorized from the skin. The straps were trimmed at the level of the skin, allowing the stumps to recoil into the subcutaneous space. The animals were euthanized at 1 and 4 months to determine the integration of the straps. RESULTS Macroscopically, all 24 straps were firmly incorporated within the abdominal wall. The tension-free placement of the mesh by using the straps was effective. The friction of the straps passing through the tissues was adequate to keep the mesh well orientated. No dislocation of the implants was observed. The strap system also allowed a broader coverage of the abdominal wall, far beyond the wound opening. CONCLUSIONS The described arm system of the aforementioned implant seems to be effective in eliminating point fixation of the mesh. The fixation arms seemed to have ensured that the mesh stayed orientated in all of the animals. A very wide lateral mesh placement was accomplished, assuring sufficient defect overlap when shrinkage occurs.
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Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010; 148:544-58. [PMID: 20304452 DOI: 10.1016/j.surg.2010.01.008] [Citation(s) in RCA: 694] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 01/14/2010] [Indexed: 12/13/2022]
Abstract
Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials.
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Comparison of anchoring capacity of mesh fixation devices in ventral hernia surgery. Surg Laparosc Endosc Percutan Tech 2009; 19:345-7. [PMID: 19692889 DOI: 10.1097/sle.0b013e3181b1e54b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND A reliable method of fixation of intraperitoneal mesh is required both in laparoscopic and open surgery for ventral hernia. We evaluated anchoring capacity of 3 fixation devices available for clinical use. MATERIALS AND METHODS Anchoring capacity of 3 commercially available fixation devices were compared by counting the number of sheets anchored by a single firing under a fixed pressure. A total of 5 trials were conducted for each device. RESULTS The number of sheets fixed (mean+/-SD) were, 12.4+/-1.1 for a coil type; 11.4+/-1.3 for a helical type; and 5.8+/-0.5 for a staple type tacker. The fixation capacity of the staple type was significantly lower than the other 2 types (P<0.0001). However, there was not statistically significant difference between the coil type and the helical type tackers. CONCLUSIONS The helical and coil type tackers in ventral hernia equally provide deep penetration that may contribute to strong fixation of the intraperitoneal mesh to the abdominal wall.
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Abstract
Ventral hernia repair remains one of the most common operations performed by general surgeons. Despite the frequency with which this procedure is performed, there is little agreement and extensive controversy as to the cause of most of the hernias, or the ideal approach to repair these complicated problems. This article attempts to identify and provide some clarification of these controversial issues in abdominal wall reconstruction after ventral herniation based on the available literature.
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Roth JS, Dexter DD, Lumpkins K, Bochicchio GV. Hydrated vs. freeze-dried human acellular dermal matrix for hernia repair: a comparison in a rabbit model. Hernia 2008; 13:201-7. [PMID: 19023639 DOI: 10.1007/s10029-008-0453-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 10/24/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abdominal wall hernias commonly occur following laparotomy. Biologic grafts are used to treat these hernias due to their biocompatibility and their ability to serve as a matrix for tissue regeneration and remodeling. Freeze-dried human acellular dermal matrices (F-HADMs) have been shown to be effective in abdominal wall defect repair. Hydrated human acellular dermal matrices (H-HADMs) have not been previously evaluated. This study evaluates H-HADM and F-HADM in the repair of abdominal wall hernias in the rabbit. METHODS Thirty-six 3-4-kg New Zealand white rabbits underwent laparotomy with the creation of a hernia. After defect reperitonealization, the animals underwent hernia repair with H-HADM, F-HADM, or primary repair. Within each group, four animals were survived for 4, 8, and 20 weeks. The outcomes evaluated included recurrences, adhesions, histology, immunohistochemistry, and tensiometry. RESULTS Thirty-five animals underwent abdominal wall hernia repair. One animal in the F-HADM group developed a recurrent hernia. No significant difference was demonstrated in adhesion scores between the H-HADM (0.75) and F-HADM (0.83) groups. Tensiometry demonstrated no differences in the forces required to disrupt the graft from the native fascia between H-HADM and F-HADM at any time point. H-HADM demonstrated fewer white blood cells (WBC) and eosinophils (EOS) per high-powered field (hpf) than F-HADM at 4 weeks (144 WBC/hpf vs. 534 WBC/hpf, P < 0.05; 87 EOS/hpf vs. 304 EOS/hpf, P < 0.05) and 8 weeks (104 WBC/hpf vs. 314 WBC/hpf, P < 0.05; 41 EOS/hpf vs. 149 EOS/hpf, P < 0.05). At 20 weeks, there was no difference in WBC or EOS (134 WBC/hpf vs. 144 WBC/hpf, P = NS; 86 EOS/hpf vs. 104 EOS/hpf, P = NS). Immunohistochemistry for CD31 demonstrated no difference in vascularity at any time point. CONCLUSIONS H-HADM and F-HADM demonstrate comparable results in abdominal wall hernia treatment in a rabbit model. With both grafts, the weakest area of the repair occurs at the graft and native fascia interface. Hernia repairs with H-HADM and F-HADM demonstrate similar incidences of adhesions and tensile strength characteristics. H-HADM demonstrates a reduced inflammatory response at 4 and 8 weeks compared to F-HADM. Both H-HADM and F-HADM demonstrate similar amounts of vascular ingrowth.
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Affiliation(s)
- J S Roth
- Department of Surgery, University of Kentucky College of Medicine, 800 Rose Street, Lexington, KY 40536, USA.
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Wassenaar EB, Schoenmaeckers EJP, Raymakers JTFJ, Rakic S. Recurrences after laparoscopic repair of ventral and incisional hernia: lessons learned from 505 repairs. Surg Endosc 2008; 23:825-32. [PMID: 18813986 DOI: 10.1007/s00464-008-0146-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 07/13/2008] [Accepted: 07/31/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND All hernia recurrences in a series of 505 patients who underwent laparoscopic repair of a ventral hernia (n=291) or incisional hernia (n=214) were analyzed to identify factors responsible for the recurrence. METHODS In all laparoscopic repairs, an expanded polytetrafluoroethylene prosthesis overlapping the hernia margins by >or=3 cm was fixed with a double ring of tacks alone (n=206) or with tacks as well as sutures (n=299). During the mean follow-up time of 31.3 +/- 18.4 months, nine patients (1.8%) had a recurrence, eight of which were repaired laparoscopically. Operative reports and videotapes of all initial repairs and repairs of recurrences were analyzed. RESULTS All recurrences followed an incisional hernia repair (p<0.001). Five recurrences developed after mesh fixation with both tacks and sutures and four after mesh fixation with tacks alone (p=1.0). All recurrences were at the site of the apparently sufficient original incision scar: in eight patients, the recurrent hernia was attached to the mesh; in one, it developed in another part of the scar. All initial repairs had been performed without technical errors. Upon repair of the recurrences, a new, larger mesh was placed over the entire incision, not just the hernia. There were no re-recurrences during follow-up (mean 19.8+/-10.3 months). CONCLUSIONS Recurrence after incisional hernia repair appears to be due primarily to disregard for the principle that the whole incision--not just the hernia--must be repaired. Our experience supports the idea that the entire incision has a potential for hernia development. Insufficient coverage of the incision scar is a risk factor for recurrence after laparoscopic repair of ventral and incisional hernia.
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Affiliation(s)
- Eelco B Wassenaar
- Department of Surgery, Twenteborg Hospital, Postbox 7600, 7600 SZ Almelo, The Netherlands.
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