Suture, synthetic, or biologic in contaminated ventral hernia repair

Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors

Importance

Recurrence is one of the most challenging adverse events after ventral hernia repair as it impacts quality of life, utilization of resources, and subsequent need for re-repair. Rates of recurrence range from 30% to 80% after ventral hernia repair.

Objective

To determine the contemporary ventral hernia recurrence rate over time in patients with previous hernia repair and to determine risk factors associated with recurrence.

Design, Setting, and Participants

This retrospective, population-based study used the Abdominal Core Health Quality Collaborative registry to evaluate year-over-year recurrence rates in patients with prior ventral hernia repair between January 2012 and August 2022. Patients who underwent at least 1 prior ventral hernia repair were included and categorized into 2 groups based on mesh or no-mesh use. There were 43 960 eligible patients; after exclusion criteria (patients with concurrent inguinal hernias as the primary diagnosis, nonstandard hernia procedure categories, American Society of Anesthesiologists class unassigned, or no follow-up), 29 834 patients were analyzed in the mesh group and 5599 in the no-mesh group.

Main Outcomes and Measures

Ventral hernia recurrence rates. Risk factors analyzed include age, body mass index, sex, race, insurance type, medical comorbidities, American Society of Anesthesiologists class, smoking, indication for surgery, concomitant procedure, hernia procedure type, myofascial release, fascial closure, fixation type, number of prior repairs, hernia width, hernia length, mesh width, mesh length, operative approach, prior mesh placement, prior mesh infection, mesh location, mesh type, postoperative surgical site occurrence, postoperative surgical site infection, postoperative seroma, use of drains, and reoperation.

Results

Among 29 834 patients with mesh, the mean (SD) age was 57.17 (13.36) years, and 14 331 participants (48.0%) were female. Among 5599 patients without mesh, the mean (SD) age was 51.9 (15.31) years, and 2458 participants (43.9%) were female. When comparing year-over-year hernia recurrence rates in patients with and without prior mesh repair, respectively, the Kaplan Meier analysis showed a recurrence rate of 201 cumulative events with 13 872 at risk (2.8%) vs 104 cumulative events with 1707 at risk (4.0%) at 6 months; 411 cumulative events with 4732 at risk (8.0%) vs 184 cumulative events with 427 at risk (32.6%) at 1 year; 640 cumulative events with 1518 at risk (19.7%) vs 243 cumulative events with 146 at risk (52.4%) at 2 years; 731 cumulative events with 670 at risk (29.3%) vs 258 cumulative events with 73 at risk (61.4%) at 3 years; 777 cumulative events with 337 at risk (38.5%) vs 267 cumulative events with 29 at risk (71.2%) at 4 years; and 798 cumulative events with 171 at risk (44.9%) vs 269 cumulative events with 19 at risk (73.7%) at 5 years. Higher body mass index; immunosuppressants; incisional and parastomal hernias; a robotic approach; greater hernia width; use of a biologic or resorbable synthetic mesh; and complications, such as surgical site infections and reoperation, were associated with higher odds of hernia recurrence. Conversely, greater mesh width, myofascial release, and fascial closure had lower odds of recurrence. Hernia type was the most important variable associated with recurrence.

Conclusions and Relevance

In this study, the 5-year recurrence rate after ventral hernia repair was greater than 40% and 70% in patients with and without mesh, respectively. Rates of ventral hernia recurrence increased over time, underscoring the importance of close, long-term follow up in this population.

Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction

PURPOSE

Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages.

METHODS

A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy.

RESULTS

Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05).

CONCLUSION

Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.

Mesh Type With Ventral Hernia Repair: A Systematic Review and Meta-analysis of Randomized Trials

INTRODUCTION

Synthetic mesh is widely utilized for clean ventral hernia repair; however, it is unclear if synthetic mesh provides the same benefits with high-risk patients or during contaminated cases. Many surgeons use biologic mesh in these settings, but there is little evidence to support this practice. Our objective was to compare the clinical outcomes of utilizing biologic mesh versus synthetic mesh during ventral hernia repair.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a review of the literature was conducted using Cochrane library, EMBASE, Clinicaltrials.gov, and PubMed for randomized controlled trials published that compared biologic versus synthetic mesh during ventral hernia repair. The primary outcome was major complications defined as deep or organ space surgical site infection, reoperations, and hernia recurrences.

RESULTS

Of 1889 manuscripts screened, four publications were included. The four studies included a total of 758 patients, with 381 receiving biologic mesh and 377 receiving synthetic mesh. Compared to biologic mesh, synthetic mesh had lower rates of major complications (38.6% versus 23.4, risk ratio = 0.55, 95% confidence interval = 0.35 to 0.86, P = 0.009) and hernia recurrence (24.5 % versus 10.3%, risk ratio = 0.44, 95% confidence interval = 0.28 to 0.69, P = 0.004). In addition, there was a lower percentage of surgical site infection and reoperation in the synthetic mesh group.

CONCLUSIONS

Contrary to current surgical teaching, placement of permanent synthetic mesh into a contaminated field yielded rates of complications that were comparable or reduced compared to biologic mesh.

The Effects of Pectin-Honey Hydrogel in a Contaminated Chronic Hernia Model in Rats

Incisional hernia is a frequent complication after abdominal surgery. A previous study on rats evaluated the use of a Pectin-Honey Hydrogel (PHH)-coated polypropylene (PP) mesh for the healing of acute hernias. However, there are no studies investigating the use of PHH in association with PP mesh in chronic contaminated hernia. The aims of this study are to assess the effectiveness of PHH in promoting abdominal hernia repaired with PP mesh and in counteracting infection. Twenty Sprague Dawley male rats were enrolled and a full thickness defect was made in the abdominal wall. The defect was repaired after 28 days using a PP mesh, and a culture medium (Tryptone Soy Broth, Oxoid) was spread onto the mesh to contaminate wounds in both groups. The rats were randomly assigned to a treated or untreated group. In the treated group, a PHH was applied on the mesh before skin closure. At euthanasia-14 days after surgery-macroscopical, microbiological and histopathological evaluations were performed, with a score attributed for signs of inflammation. An immunohistochemical investigation against COX-2 was also performed. Adhesions were more severe (p = 0.0014) and extended (p = 0.0021) in the untreated group. Bacteriological results were not significantly different between groups. Both groups showed moderate to severe values (score > 2) in terms of reparative and inflammatory reactions at histopathological levels. The use of PHH in association with PP mesh could reduce adhesion formation, extension and severity compared to PP mesh alone. No differences in terms of wound healing, contamination and grade of inflammation were reported between groups.

Readmissions after emergent incisional ventral hernia repair: a retrospective review of the nationwide readmissions database

Emergent ventral hernia repair (eVHR) is associated with significant morbidity, yet there is no consensus regarding optimal surgical approach. We hypothesized that eVHR with synthetic mesh would have a higher readmission rate compared to primary eVHR or biologic mesh repair. Retrospective analysis of the Nationwide Readmissions Database (NRD) was conducted for patient entries between 2016 and 2018. Adult patients who underwent eVHR were included. Patient demographics, comorbidities, and surgical techniques were compared between readmitted and non-readmitted patients. Predictors of readmission were assessed using multivariate analysis with propensity weighting for various eVHR techniques. Secondary outcomes included hospital length of stay and readmission diagnoses. 43,819 patients underwent eVHR; of the 22,732 with 6 months of follow-up, 6382 (28.1%) were readmitted. The majority of readmissions occurred within the first 30 days (51.8%). Over half of the readmissions were related to surgical complications (50.6%), the most common being superficial surgical site infection (30.1%) and bowel obstruction/ileus (12.2%). In the multivariate analysis, predictors of 30-day readmission included use of synthetic mesh (OR 1.07, 95% CI 1.00-1.14), biologic mesh (OR 1.26, 95% CI 1.06-1.49), and need for concomitant large bowel resection (OR 1.46, 95% CI 1.30-1.65). eVHR is associated with high rates of readmission. Primary repair had favorable odds for readmission and lower risk of surgical complications compared to synthetic and biologic mesh repairs. Synthetic repair had lower odds of readmission than biologic repair. Given the inherent limitations of the NRD, further institutional prospective studies are required to confirm these findings.

Slowly absorbable mesh in sublay ventral hernia repair in contaminated fields

BACKGROUND

In the past years, there has been increasing evidence that supports the use of permanent mesh in contaminated wounds. Given this increased evidence, the indications to opt for slowly absorbable "biosynthetic" prostheses have been questioned. To address this, we compared the outcomes of slowly absorbable mesh in contaminated cases in a well-matched multicentric cohort.

METHODS

The Abdominal Core Health Quality Collaborative (ACHQC) database was queried for patients undergoing elective ventral hernia repair in Centers for Disease Control (CDC)-III operations (2013-2022). We compared demographics, hernia characteristics, and postoperative outcomes among types of mesh. We used propensity score matching to adjust for sex, diabetes, body mass index, smoking status, and operative time between mesh groups. Patients within other CDC classes and those with mesh positioned elsewhere than retro-rectus/preperitoneal space were excluded.

RESULTS

A total of 760 patients were included in the analysis. Slowly absorbable synthetic mesh (SA) was utilized in only 7% of the cases, while permanent (P) and biologic (B) mesh in 77% and 16%, respectively. After matching, 255 patients were studied. There was no difference in surgical site occurrence (8% SA, 16% P, 10% B, p = 0.27), surgical site infection (20% SA, 17% P, 12% B p = 0.54), surgical site occurrence requiring intervention (18% SA, 13% P, 14% B p = 0.72), readmission (12% SA, 14% P, 12% B, p = 0.90), or reoperation (8% SA, 2% P, 4% B, p = 0.14) at 30 days. In patients with 1-year follow-up, there was no difference in recurrence among groups (20% SA, 26% P, 24% B p = 0.90).

CONCLUSION

Based on our findings, SA has comparable outcomes to other types of mesh, particularly when an optimal retro-rectus repair is performed.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Retrorectus mesh reinforcement of ileostomy site fascial closure: stoma closure and reinforcement (SCAR) trial phase I/II results

PURPOSE

Loop ileostomy (LI) is commonly employed during colorectal surgeries to reduce the consequences of anastomotic leak. Unfortunately, LI is associated with a 10-30% incisional hernia (IH) rate after closure. We hypothesized that prophylactic mesh reinforcement during LI takedown would safely prevent subsequent IH formation.

METHODS

This single-center, phase I/II prospective study evaluated adult patients undergoing LI closure after left-sided colorectal cancer procedures. After LI closure, the posterior rectus sheath was mobilized and reapproximated with absorbable suture. A reduced-weight, macroporous, polypropylene mesh (Softmesh, BD) was placed in the retrorectus position to allow 3 cm of overlap and secured with fibrin sealant. The anterior fascia was closed with slowly absorbable suture. CT images obtained for cancer surveillance were reviewed by a radiologist blinded to the study intervention to evaluate for evidence of hernia or surgical site occurrence (SSO).

RESULTS

Twenty patients were included with mean defect and mesh sizes of 11.2 cm² and 64.2 cm², respectively. Mean operative time for LI takedown and mesh augmented closure was 84 min with mesh implantation time being 16.4 min. Two patients were readmitted within 30 days for ileus, no patient required procedural intervention. Over a mean follow-up period of 20 ± 7 months, no SSO or hernias were observed clinically or on CT imaging.

CONCLUSION

In our small series, retromuscular mesh reinforcement of LI closure appears feasible, safe and effective. This mesh reinforcement approach should be further investigated to evaluate its long-term effectiveness.

An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair

Purpose:  Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods:  A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results:  Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects. Rives-Stoppa sublay mesh repair has become the "gold" standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature. Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned. Conclusions:  Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.

Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial

IMPORTANCE

Biologic mesh is widely used for reinforcing contaminated ventral hernia repairs; however, it is expensive and has been associated with high rates of long-term hernia recurrence. Synthetic mesh is a lower-cost alternative but its efficacy has not been rigorously studied in individuals with contaminated hernias.

OBJECTIVE

To determine whether synthetic mesh results in superior reduction in risk of hernia recurrence compared with biologic mesh during the single-stage repair of clean-contaminated and contaminated ventral hernias.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, single-blinded randomized clinical trial was conducted from December 2012 to April 2019 with a follow-up duration of 2 years. The trial was completed at 5 academic medical centers in the US with specialized units for abdominal wall reconstruction. A total of 253 adult patients with clean-contaminated or contaminated ventral hernias were enrolled in this trial. Follow-up was completed in April 2021.

INTERVENTIONS

Retromuscular synthetic or biologic mesh at the time of fascial closure.

MAIN OUTCOMES AND MEASURES

The primary outcome was the superiority of synthetic mesh vs biologic mesh at reducing risk of hernia recurrence at 2 years based on intent-to-treat analysis. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrence requiring a procedural intervention, and 30-day hospital direct costs and prosthetic costs.

RESULTS

A total of 253 patients (median [IQR] age, 64 [55-70] years; 117 [46%] male) were randomized (126 to synthetic mesh and 127 to biologic mesh) and the follow-up rate was 92% at 2 years. Compared with biologic mesh, synthetic mesh significantly reduced the risk of hernia recurrence (hazard ratio, 0.31; 95% CI, 0.23-0.42; P < .001). The overall intent-to-treat hernia recurrence risk at 2 years was 13% (33 of 253 patients). Recurrence risk with biologic mesh was 20.5% (26 of 127 patients) and with synthetic mesh was 5.6% (7 of 126 patients), with an absolute risk reduction of 14.9% with the use of synthetic mesh (95% CI, -23.8% to -6.1%; P = .001). There was no significant difference in overall 2-year risk of surgical site occurrence requiring a procedural intervention between the groups (odds ratio, 1.22; 95% CI, 0.60-2.44; P = .58). Median (IQR) 30-day hospital direct costs were significantly greater in the biologic group vs the synthetic group ($44 936 [$35 877-$52 656] vs $17 289 [$14 643-$22 901], respectively; P < .001). There was also a significant difference in the price of the prosthetic device between the 2 groups (median [IQR] cost biologic, $21 539 [$20 285-$23 332] vs synthetic, $105 [$105-$118]; P < .001).

CONCLUSIONS AND RELEVANCE

Synthetic mesh demonstrated superior 2-year hernia recurrence risk compared with biologic mesh in patients undergoing single-stage repair of contaminated ventral hernias, and both meshes demonstrated similar safety profiles. The price of biologic mesh was over 200 times that of synthetic mesh for these outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02451176.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review

INTRODUCTION

The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations.

METHODS

We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis.

RESULTS

Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial.

CONCLUSION

A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields: Outcomes with Poly-4-Hydroxybutyrate Mesh

BACKGROUND

Hernia repair in the setting of contamination poses unique challenges, including complications such as recurrence and mesh infection. The ideal contaminated hernia repair including type of mesh use remains controversial. Poly-4-hydroxybutyrate is a biosynthetic scaffold for soft-tissue reinforcement and hernia repair and is potentially useful in contaminated hernia repair. The authors aim to describe postoperative outcomes, recurrence, and patient-reported outcomes after contaminated hernia repair with poly-4-hydroxybutyrate.

METHODS

Adult patients (≥18 years) undergoing a contaminated hernia repair with poly-4-hydroxybutyrate (Phasix) performed by a single plastic surgeon between January of 2015 and May of 2020 were identified. Patients with a ventral hernia defect and a Centers for Disease Control and Prevention wound class of II, III, or IV were included. Primary outcomes included recurrence, surgical-site infection, surgical-site occurrences, and surgical-site infection/occurrences requiring procedural interventions. As a secondary outcome, the authors assessed patient-reported outcomes as defined by the Abdominal Hernia-Q and Hernia-Related Quality of Life Survey.

RESULTS

Sixty patients were included with a median age of 52.5 and body mass index of 31 kg/m2. Median defect size was 300 cm2. Twenty-eight patients (46.7 percent) experienced a complication. The most common complications were surgical-site occurrence [n = 20 (33.3 percent)] and surgical-site infection [n = 10 (16.7 percent)]. Median follow-up was 24.2 months, with a recurrence rate of 8.3 percent (n = 4). Overall patient-reported outcomes improved postoperatively, and improvement was not affected by the presence of a complication.

CONCLUSIONS

Poly-4-hydroxybutyrateuse in contaminated hernia repair shows promising results with an acceptable safety profile. Although complications are frequent in this complex cohort, patient-reported outcomes improvement was significant even in patients with complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Herniorrhaphy Lamination Technique for the Reconstruction of Midline Abdominal Wall Defects

The primary goal of abdominal wall reconstruction is to prevent hernia recurrence through robust and durable repair. Synthetic mesh utilization can provide sound strength but is susceptible to extrusion, infection, and intestinal fistulization. The use of autologous fasciae latae to reinforce the primary fascial reapproximation has mostly been abandoned, presumably because synthetic patches are readily available. There is a specific demand for a sustainable, less-invasive, and ready-to-use repair method without mesh. The authors devised a herniorrhaphy lamination technique using local musculofascial flaps inspired by composite laminates. In this procedure, the primary fascial reapproximation is reinforced with 3 additional laminated musculofascial layers: (1) turnover hinge flaps of the anterior sheath of the rectus abdominis, (2) bilateral rectus abdominis, and (3) advancement flaps of newly generated edges of the fascia of the rectus sheath. Our technique’s stability is essentially due to the mechanical superiority of the centralized pipe-like structure of musculofascia. Between February 2009 and November 2019, we used the lamination technique to repair midline incisional hernias in 10 patients. The operative procedure was successful in all patients, and there has been no evidence of recurrence. The follow-up period ranged from 12 to 69 months, with a mean follow-up of 35 months. The herniorrhaphy lamination technique to reinforce the primary repair can help prevent hernia recurrence. Although our technique is suitable for a small-sized defect, it is less invasive, and can be readily applied. Because it does not include any mesh, it is suitable for the contaminated abdominal wall reconstruction.

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02041494.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic, level I.

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

Background

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

Methods

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

Results

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

Conclusions

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

Effectiveness and Safety of Mesh Repair for Incarcerated or Strangulated Hernias: A Systematic Review and Meta-Analysis

BACKGROUND

Hernia repair with mesh in patients with incarcerated or strangulated hernias is controversial. Moreover, the use of mesh for hernia repair with concomitant bowel resection poses a great dilemma. This study compared the outcomes of mesh and anatomic repairs in patients with acutely incarcerated or strangulated hernias.

METHODS

PubMed, Embase, and Cochrane databases were searched for studies published before November 2019. Randomized controlled trials (RCTs) and prospective studies were included. We conducted meta-analyses using a random-effects model. The treatment outcome was measured by the incidence of surgical site infection (SSI), seroma formation, and hernia recurrence postoperatively.

RESULTS

Two RCTs and six prospective studies with 978 patients were included. No significant difference in SSI incidence was observed between patients with incarcerated hernia from the mesh and anatomic repair groups. Recurrence was significantly lower in mesh repair group than in anatomic repair group (odds ratio, 0.08; 95% confidence interval, 0.01-0.45). Only two patients needed to have mesh explantation due to mesh infection. In the setting of hernia repair with concomitant bowel resection, the SSI rate with mesh repair was slightly higher, but most cases of infections were well controlled with conservative antibiotic therapy.

CONCLUSIONS

Mesh repair for incarcerated or strangulated hernias was feasible with a great benefit of lower recurrence rates. However, due to limited data, drawing conclusions regarding the use of mesh for hernia repair with concomitant bowel resection was difficult. Further studies with preset criteria for evaluating patients undergoing concomitant bowel resection may help elucidate this issue.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients

BACKGROUND

In recent decades, biologic mesh (BM) has become an important adjunct to surgical practice. Recent evidence-based clinical applications of BM include but are not limited to: reconstruction of abdominal wall defects; breast reconstruction; face, head and neck surgery; periodontal surgery; other hernia repairs (diaphragmatic, hiatal/paraesophageal, inguinal and perineal); hand surgery; and shoulder arthroplasty. Prior systematic reviews of BM in complex abdominal wall hernia repair had several shortcomings that our comprehensive review seeks to address, including exclusion of laparoscopic repair, assessment of risk of bias, use of an acceptable meta-analytic method and review of risk factors identified in multivariable regression analyses.

MATERIALS AND METHODS

We sought articles of BM for open ventral hernia repair reporting on early complications, late complications or recurrences and included minimum of 50. We used the quality in prognostic studies risk of bias assessment tool. Random effects meta-analysis was applied.

RESULTS

This comprehensive review selected 62 articles from 51 studies that included 6,079 patients. Meta-analytic pooling found that early complications are present in about 50%, surgical site occurrences (SSOs) in 37%, surgical site infections (SSIs) in 18%, reoperation in 7%, readmission in 20% and mortality in 3%. Meta-analytic estimates of late outcomes included overall complications (42%), SSOs (40%) and SSIs (22%). Specific SSOs included seroma (14%), hematoma (4%), abscess (10%), necrosis (5%), dehiscence (8%) and fistula formation (5%). Reoperation occurred in about 17%, mesh explantation in 9% and recurrence in 36%.

CONCLUSION

Estimates of nearly all outcomes from individual studies were highly heterogeneous and sensitivity analyses and meta-regressions generally failed to explain this heterogeneity. Recurrence is the only outcome for which there are consistent findings for risk factors. Bridge placement of BM is associated with higher risk of recurrence. Prior hernia repair, history of reintervention and history of mesh removal were also risk factors for increased recurrence.

Synthetic versus Biologic Mesh for Complex Open Ventral Hernia Repair: A Pilot Randomized Controlled Trial

Background: Many surgeons utilize biologic mesh for elective complex ventral hernia repair (VHR; large hernias, contaminated fields, or patients with comorbid conditions). However, no randomized controlled trials (RCTs) have compared biologic and synthetic mesh. We hypothesize biologic mesh would result in fewer major complications at one-year post-operative compared with synthetic mesh. Patients and Methods: We performed a single-center, pilot RCT. All eligible patients undergoing complex, open VHR were randomly assigned to receive biologic or synthetic mesh placed in the retromuscular position. Primary outcome was major complications, namely, a composite of mesh infection, recurrence, or re-operation at one-year post-operative. Secondary outcomes included surgical site infections (SSI), seromas, hematomas, wound dehiscence, re-admissions, and Clavien-Dindo complication grade. Outcomes were assessed using Fisher exact test and Bayesian generalized linear models. Results: Of 87 patients, 44 were randomly assigned to biologic mesh and 43 to synthetic mesh. Most cases were wound class 2-4 (68%) and 75% had a hernia width >4 cm. Most patients were obese (70%) and had an American Society of Anesthesiogists (ASA) score of 3-4 (53%). Compared with patients in the synthetic mesh group, patients in the biologic mesh group had a higher percentage of: major complications at one-year post-operative (42.4% vs. 21.6%; relative risk [RR] = 1.96 [95% confidence interval {CI} = 0.94-4.08]; number needed to harm = 4.8; p = 0.071); SSI (15.9% vs. 9.3%; RR = 1.71 [95% CI = 0.54-5.42]; p = 0.362); wound dehiscence (25.0% vs. 14.0%; RR = 1.79 [95% CI = 0.73-4.41]; p = 0.205); and re-admissions (22.7% vs 9.3%; RR = 2.44 [95% CI = 0.83-7.20]; p = 0.105). Bayesian analysis demonstrated that compared with synthetic mesh, biologic mesh had a 95% probability of increased risk of major complications at one-year post-operative. No clear evidence of a difference was found on seromas, hematomas, or Clavien-Dindo complication grade. Conclusions: In elective complex open VHR, biologic mesh demonstrated no benefit compared with synthetic mesh in one-year outcomes. Moreover, Bayesian analysis suggests that biologic mesh may have an increased probability of major complications.

Decellularization and In Vivo Recellularization of Abdominal Porcine Fascial Tissue

BACKGROUND

Tissue decellularization has evolved as a promising approach for tissue engineering applications.

METHODS

In this study, we harvested fascial tissue from porcine anterior abdominal wall and the samples were decellularized with a combination of agents such as Triton X-100, trypsin and DNAase. Afterwards, we evaluated cell removal by histological analysis and DNA quantification. Mechanical functionality was evaluated by applying a range of hydrostatic pressures. A sample of decellularized fascia was transplanted into a rabbit and after 15 days a biopsy of this tissue was examined; the animal was observed during 6 months after surgery.

RESULTS

The extracellular matrix was retained with a complete decellularization as evidenced by histologic examination. The DNA content was significantly reduced. The scaffold preserved its tensile mechanical properties. The graft was incorporated into a full thickness defect made in the rabbit abdominal wall. This tissue was infiltrated by granulation and inflammatory cells and the histologic structure was preserved 15 days after surgery. The animal did not develop hernias, infections or other complications, after a 6-months of follow up.

CONCLUSIONS

The protocol of decellularization of fascial tissue employed in this study proved to be efficient. The mechanical test demonstrated that the samples were not damaged and maintained its physical characteristics; clinical evolution of the rabbit, recipient of the decellularized fascia, demonstrated that the graft was effective as a replacement of native tissue.In conclusion, a biological scaffold derived from porcine fascial tissue may be a suitable candidate for tissue engineering applications.

Repair of a medium-sized ventral hernia with the UltraPro Hernia System

Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.

A novel biosynthetic scaffold mesh reinforcement affords the lowest hernia recurrence in the highest-risk patients

INTRODUCTION

Patients with higher postoperative infection risk undergoing ventral hernia repair (VHR) have limited options for mesh use. Biosynthetic mesh is intended to utilize the durability of synthetic mesh combined with the biocompatibility of biologic mesh. We sought to assess the outcomes of a novel biosynthetic scaffold mesh for VHR in higher risk patients over a 12-month postoperative period.

METHODS

Two cohorts of 50 consecutive patients who underwent VHR with TELA Bio OviTex biosynthetic or synthetic mesh were retrospectively compared. Endpoints included surgical site occurrence (SSO), readmission rate, and hernia recurrence following VHR at 12 months postoperatively.

RESULTS

OviTex mesh placement was associated with higher risk Ventral Hernia Working Group (VHWG) distribution and more contaminated CDC wound class distribution compared to synthetic mesh placement (VHWG grade 3: 68% vs. 6%, p < 0.001; CDC class > I: 70% vs. 6%, p < 0.001). Additionally, concomitant procedures were performed more often with OviTex mesh placement than synthetic mesh placement (70% vs 10%, p < 0.001). The OviTex mesh performed comparably to synthetic mesh in terms of incidences of SSO (36% vs 22%, p = 0.19), readmission rates (24% vs 14%, p = 0.31), and hernia recurrence (6% vs 12%, p = 0.74). On further evaluation, patients who developed SSO with OviTex mesh (n = 18) had a 17% hernia recurrence whereas those with synthetic mesh (n = 11) had an associated 55% hernia recurrence (p = 0.048).

CONCLUSIONS

The OviTex biosynthetic mesh was used in higher risk patients and performed similarly to synthetic mesh in regards to rate of SSO, readmissions, and hernia recurrence. Furthermore, patients who developed SSO with Ovitex mesh were significantly less likely to have hernia recurrence than those with synthetic mesh. Overall, the data suggest that biosynthetic mesh is a more desirable option for definitive hernia repair in higher risk patients.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Prophylactic biological mesh reinforcement versus standard closure of stoma site (ROCSS): a multicentre, randomised controlled trial

BACKGROUND

Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site.

METHODS

In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.

FINDINGS

Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43-0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26-0·69; p<0·001). There was also a reduction in symptomatic hernia (16%, 52 of 329 vs 19%, 64 of 331; adjusted relative risk 0·83, 0·60-1·16; p=0·29) and surgical reintervention (12%, 42 of 344 vs 16%, 54 of 346: adjusted relative risk 0·78, 0·54-1·13; p=0·19) at 2 years, but this result did not reach statistical significance. No significant differences were seen in wound infection rate, seroma rate, quality of life, pain scores, or serious adverse events.

INTERPRETATION

Reinforcement of the abdominal wall with a biological mesh at the time of stoma closure reduced clinically detectable incisional hernia within 24 months of surgery and with an acceptable safety profile. The results of this study support the use of biological mesh in stoma closure site reinforcement to reduce the early formation of incisional hernias.

FUNDING

National Institute for Health Research Research for Patient Benefit and Allergan.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Abdominal Compartment Syndrome: Improving Outcomes With A Multidisciplinary Approach - A Narrative Review

Abdominal compartment syndrome (ACS) refers to a severe increase in intra-abdominal pressure associated with single or multiorgan failure. ACS with specific pathophysiological processes and detrimental outcomes may occur in a variety of clinical conditions. Patients with ACS are predominantly managed in critical care settings, however, a wide range of multidisciplinary interventions are frequently required from medical, surgical, radiological and nursing specialties. The medical management, aiming to prevent the progression of intra-abdominal hypertension to ACS, is extensively reviewed. Timing and techniques of surgical decompression techniques, as well as management of open abdomen, are outlined. In summary, the current narrative review provides data on history, definitions, epidemiology and pathophysiology of the syndrome and highlights the importance of multidisciplinary approach in the management of ACS in adults.

Costs and Complications Associated with Infected Mesh for Ventral Hernia Repair

Background: Mesh hernia repair is widely accepted because of the associated reduction in hernia recurrence compared with suture-based repair. Despite initiatives to reduce risk, mesh infection and mesh removal are a significant challenge. In an era of healthcare value, it is essential to understand the global cost of care, including the incidence and cost of complications. The purpose of this study was to identify the outcomes and costs of care of patients who required the removal of infected hernia mesh. Methods: A review of databases from 2006 through June 2018 identified patients who underwent both ventral hernia repair (VHR) and re-operation for infected mesh removal. Patient demographic and operative details for both procedures, including age, Body Mass Index, mesh type, amount of time between procedures, and information regarding interval procedures were obtained. Clinical outcome measures were the length of the hospital stay, hospital re-admission, incision/non-incision complications, and re-operation. Hospital cost data were obtained from the cost accounting system and were combined with the clinical data for a cost and clinical representation of the cases. Results: Thirty-four patients underwent both VHR and removal of infected mesh material over the 12-year time frame and were included in the analyses; the average age at VHR was 48 years, and 16 patients (47%) were female. Following VHR, 21 patients (62%) experienced incision complications within 90 days post-operatively, the complications ranging from superficial surgical site infection (SSI) to evisceration. A mean of 22.65 months passed between procedures. After mesh removal, 16 patients (47%) experienced further incisional complications; and 22 (65%) patients had at least one re-admission. Eighteen patients (53%) required a minimum of one additional related operative procedure after mesh removal. Median hospital costs nearly doubled (p < 0.001) for the mesh removal ($23,841 [interquartile range {IQR} $13,596-$42,148]) compared with the VHR admission ($13,394 [IQR $8,424-$22,161]) not accounting for re-admission costs. A majority experienced hernia recurrence subsequent to mesh removal. Conclusions: Mesh infection after hernia repair is associated with significant morbidity and costs. Hospital re-admission, re-operations, and recurrences are common among these patients, resulting in greater healthcare resource utilization. Development of strategies to prevent mesh infection, identify patients most likely to experience infectious complications, and define best practices for the care of patients with mesh infection are needed.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Emergency repair of complicated abdominal wall hernias: WSES guidelines

PURPOSE

In July 2013, the World Society of Emergency Surgery (WSES) held the first Consensus Conference on emergency repair of abdominal wall hernias in adult patients with the intention of producing evidence-based guidelines to assist surgeons in the management of complicated abdominal wall hernias. Guidelines were updated in 2017 in keeping with varying clinical practice: benefits resulting from the increased use of biological prosthesis in the emergency setting were highlighted, as previously published in the World Journal of Emergency Surgery. This executive summary is intended to consolidate knowledge on the emergency management of complicated hernias by providing the broad readership with a practical and concise version of the original guidelines.

METHODS

This executive manuscript summarizes the WSES guidelines reporting on the emergency management of complicated abdominal wall hernias; statements are highlighted focusing the readers' attention on the main concepts presented in the original guidelines.

CONCLUSIONS

Emergency repair of complicated abdominal hernias remains one of the most common and challenging surgical emergencies worldwide. WSES aims to provide an essential version of the evidence-based guidelines focusing on the timing of intervention, laparoscopic approach, surgical repair following the Centers for Disease Control and Prevention (CDC) wound classification, antimicrobial prophylaxis and anesthesia in the emergency setting.

A post-market, prospective, multi-center, single-arm clinical investigation of Phasix™ mesh for VHWG grade 3 midline incisional hernia repair: a research protocol

Background

Incisional heia is a frequent complication of midline laparotomy. The use of mesh in hernia repair has been reported to lead to fewer recurrences compared to primary repair. However, in Ventral Hernia Working Group (VHWG) Grade 3 hernia patients, whose hernia is potentially contaminated, synthetic mesh is prone to infection. There is a strong preference for resorbable biological mesh in contaminated fields, since it is more able to resist infection, and because it is fully resorbed, the chance of a foreign body reaction is reduced. However, when not crosslinked, biological resorbable mesh products tend to degrade too quickly to facilitate native cellular ingrowth. Phasix™ Mesh is a biosynthetic mesh with both the biocompatibility and resorbability of a biological mesh and the mechanical strength of a synthetic mesh. This multi-center single-arm study aims to collect data on safety and performance of Phasix™ Mesh in Grade 3 hernia patients.

Methods

A total of 85 VHWG Grade 3 hernia patients will be treated with Phasix™ Mesh in 15 sites across Europe. The primary outcome is Surgical Site Occurrence (SSO) including hematoma, seroma, infection, dehiscence and fistula formation (requiring intervention) through 3 months. Secondary outcomes include recurrence, infection and quality of life related outcomes after 24 months. Follow-up visits will be at drain removal (if drains were not placed, then on discharge or staple removal instead) and in the 1st, 3rd, 6th, 12th, 18th and 24th month after surgery.

Conclusion

Based on evidence from this clinical study Depending on the results this clinical study will yield, Phasix™ Mesh may become a preferred treatment option in VHWG Grade 3 patients.

Trial registration

The trial was registered on March 25, 2016 on clinicaltrials.gov: NCT02720042.

Comparison of in vivo remodeling of urinary bladder matrix and acellular dermal matrix in an ovine model

Aim: Biologically derived surgical graft materials come from a variety of sources with varying mechanical properties. This study aimed to evaluate the host response and mechanical performance of two extracellular matrix devices in a large animal preclinical model. Materials & methods: Bilateral defects were created in the fascia lata of sheep and repaired with either an acellular dermal matrix (ADM) or urinary bladder matrix (UBM). After 1 or 3 months, the repair site was explanted for histological and mechanical analysis. Results & conclusion: Despite pre-implantation mechanical differences, both UBM and ADM demonstrated similar mechanical performance at 3 months. However, UBM was completely remodeled into site-appropriate tissue by 3 months, while ADM showed limited tissue incorporation.

Retrorectus repair of incisional ventral hernia with urinary bladder matrix reinforcement in a long-term porcine model

Aim: Not all biologically derived materials elicit the same host response when used for reinforcement of ventral hernia repairs. This study aimed to evaluate the remodeling characteristics of the abdominal wall following reinforcement with urinary bladder matrix (UBM) in a large animal preclinical model of ventral hernia repair. Materials & methods: Midline defects in 36 Yucatan minipigs were reinforced with UBM-derived surgical devices using a classic Rives–Stoppa–Wantz approach, and compared with primary repair controls. After 3 or 8 months, the abdominal wall was explanted for histological and mechanical analysis. Results & conclusion: All UBM-derived surgical devices were completely resorbed within 8 months and facilitated deposition of vascularized, biomechanically functional connective tissue in the retrorectus plane, with no evidence of hernia formation.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION

Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.

METHODS

A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.

RESULTS

The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.

CONCLUSION

The routine use of biologic and biosynthetic meshes cannot be recommended.

Comparison of Surgeon Specialty in Open Ventral Hernia Repair

BACKGROUND

Ventral hernia repair is a common procedure and is undertaken by surgeons with varying training backgrounds. Outcomes after hernia repair depend on numerous factors, some being patient or surgeon specific. It remains unclear what the ideal roles are for general and plastic surgeons in open ventral hernia repair. We hypothesized that open ventral hernia repair by plastic surgeons is safe and comparable with general surgeons.

METHODS

We performed a retrospective observational study using data from the National Surgical Quality Improvement Program database from 2007 to 2013. Patients with a primary diagnosis of ventral hernia undergoing open repair were identified. Multivariate regression modeling was performed, adjusting for surgeon specialty, patient characteristics, common concurrent procedures, and the total number of concurrent procedures. Outcomes studied were major and minor 30-day complications, operation time, readmission, unplanned reoperation, and length of hospital stay.

RESULTS

We identified 53,746 patients who underwent open repair, 53,282 (99.1%) by general surgeons (GS) and 464 (0.9%) by plastic surgeons (PS). There were significantly different rates of concurrent panniculectomy (12.1% PS vs 2.4% GS) and component separation (24.8% PS vs 5.3% GS), representing increased PS case complexity. 52.3% of GS and 92.9% of PS performed panniculectomy without an alternate specialty surgeon. 81.3% of GS and 97.4% of PS performed component separation without an alternate specialty surgeon. The PS patients had a significantly longer uncorrected length of stay and operation time than GS patients (all P < 0.001). Similarly, PS was positively associated with uncorrected major and minor complications (P < 0.001). However, these relationships did not persist on multivariate analysis after adjusting for demographic characteristics, medical comorbidities, concurrent procedures, and total procedure load. Furthermore, PS was associated with lower odds of major complications (operating room, 0.49; P = 0.05) compared with GS.

CONCLUSIONS

Outcomes of hernia repair by plastic surgeons are comparable with general surgeons, despite plastic surgeons being involved in many complex cases. Interestingly, we identified that general surgeons are performing adjunctive procedures to ventral hernia previously handled by plastic surgeons. Although further study is warranted, we conclude that for open ventral hernia repair, plastic surgeons provide a comparable alternative to general surgeons.