Reliable complex abdominal wall hernia repairs with a narrow, well-fixed retrorectus polypropylene mesh: A review of over 100 consecutive cases

Long-term outcomes of open midline ventral hernia repair using a narrow well-fixed retrorectus polypropylene mesh

INTRODUCTION

The ultimate measure of successful abdominal wall reconstruction is a pain-free, complication-free, and durable hernia repair. Open techniques have generally lost favor, but they still have much to offer for patients with skin deficits and excess. The long-term complication rates for open hernia repairs is unknown. Electronic medical records now provide the ability to easily follow patients who have switched medical institutions. Using this tool, we followed a cohort of abdominal wall reconstruction patients who had an early high "success" rate.

METHODS

We performed a retrospective chart review of 101 patients who underwent open ventral hernia repair with a narrow well-fixed retrorectus uncoated polypropylene mesh by a single surgeon (GAD) between the years of 2010 and 2015. These patients were initially reported in a 2016 publication. Patients' post-operative follow-up by any medical provider assessing the abdominal region were studied up until August 2023. Patient demographics, operative reports, and postoperative course were re-reviewed.

RESULTS

A total of 101 patients underwent ventral hernia repair. Mean follow-up time was 7.68 years (range 1.8 - 13.0 years). There were no recurrent hernias across the studied time period and no instances of enterocutaneous fistulas. 15 patients (15%) had abdominal surgery after hernia repair unrelated to their original surgery and 5 patients (5%) reported chronic post-operative pain. 13 patients died in the follow-up period, all unrelated to the abdominal wall surgery.

CONCLUSION

Open well-fixed narrow retrorectus mesh hernia repairs perform well in the long-term without fistulas, extrusions, and hernia recurrence.

Duramesh registry study: short-term outcomes using mesh suture for abdominal wall closure

Introduction

Sutures are flexible linear elements that join tissue and maintain their hold with a surgeon-created knot. Tension at the suture/tissue interface can cut the very tissues that sutures are designed to hold, leading to dehiscence and incisional hernia formation. A new suture design (Duramesh, Mesh Suture Inc., Chicago, IL) was approved for marketing by the United States Food and Drug Administration in September 2022. The multiple filaments of the mesh suture are designed to diffuse tension at the suture/tissue interface thereby limiting pull-through. The macroporosity and hollow core of the mesh suture encourage fibrovascular incorporation for a durable repair. We created the first registry and clinical report of patients undergoing mesh suture implantation to assess its real-world effectiveness.

Methods

A patient registry was created based on institutional implant logs from January to August 2023 at an integrated health-care system. Operative reports were reviewed by the study team to verify use of "Duramesh" by dictation. Retrospective chart review was conducted to evaluate patient and surgical characteristics, follow-up, and short-term outcomes of interest. Results were analyzed using descriptive statistics and Chi-squared analysis with Microsoft Excel and GraphPad Prism.

Results

Three hundred seventy-nine separate implantations by 56 surgeons across 12 (sub) specialties at a university hospital and two community hospitals were performed. Mesh suture was used for treatment of the abdominal wall in 314 cases. Follow-up averaged 80.8 ± 52.4 days. The most common abdominal wall indications were ventral hernia repair (N = 97), fascial closure (N = 93), abdominal donor site closure from autologous breast reconstruction (N = 51), and umbilical hernia repair (N = 41). Mesh suture was used in all Centers for Disease Control (CDC) wound classifications, including 92 CDC class 2 or 3 abdominal operations. There were 19 surgical site infections (6.1%) and 37 surgical site events (11.8%).

Conclusions

Short-term registry data demonstrates the wide diversity of surgical disciplines and scenarios in which mesh suture has been used to date. The early adoption of mesh suture into practice highlights that consequences of suture pull-through influence operative decision making. As this is the first interim report of the Duramesh mesh suture registry, follow-up is too short for characterization of long-term durability of abdominal wall closures.

Novel Approach for Umbilical Hernia Repair Using Mesh Strips

Umbilical hernia repair is a common surgical procedure without a universally accepted means of repair. We introduce a novel surgical technique for open primary umbilical hernia repair, using strips of polypropylene mesh as sutures to achieve a repair.

Methods

Two-centimeter-wide strips of macroporous polypropylene mesh were passed through the abdominal wall and tied as simple interrupted sutures to achieve umbilical hernia repair. A retrospective review of all elective umbilical hernia repairs performed by a single surgeon using the mesh strip technique between 2016 and 2021 was conducted, and patient-reported outcomes were assessed via a telephonic survey.

Results

Thirty-three patients underwent an elective, open mesh strip repair of a primary umbilical hernia and met criteria for inclusion in the study. Of these patients, 60% responded to a patient-reported outcomes telephone survey. Ninety percent of survey responders reported a pain score of 0 of 10. Additionally, 90% reported being unable to feel or palpate the knot, and 80% reported an improvement in quality of life. Mean follow-up at 3 years revealed one recurrence in the setting of ascites, yielding a recurrence rate of 3%.

Conclusion

Primary mesh strip repair of umbilical hernias combines the simplicity of suture repair with the advantageous force distribution properties of mesh, and constitutes a safe, efficient, and effective method of repair with a low recurrence rate at long-term follow-up that is comparable to planar mesh repair.

Abdominal wall hernia and mental health: patients lived experiences and implications for patient care

BACKGROUND

Abdominal wall hernia (AWH) affects mental health and mental health questions are frequently included within Patient-Reported Outcome Measures (PROMS) for this patient population. However, these questions have not been informed by the subjective lived experiences of mental health in AWH patients. This study is the first to qualitatively examine how AWH affects patients' mental health.

METHODS

Fifteen patients were interviewed from a purposive sample of AWH patients until no new themes emerged. Interviews explored patient thoughts and experiences of AWH and mental health. Data were examined using Interpretative Phenomenological Analysis (IPA).

RESULTS

Three key themes pertaining to mental health were identified: "psychological and emotional distress", "identity disruption" and "coping mechanisms and support systems".

CONCLUSION

Our findings illustrate that AWH is a pathology that can have a significant detrimental impact on people's mental health. This impact has implications for patient care and can be treated and managed through better psychological support. This support may positively affect AWH patient's experience and outcomes in terms of quality of life. This paper provides recommendations for improved AWH patient care in regard to mental health.

Favourable outcomes after Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Non-Complex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-Analysis

OBJECTIVE

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

SUMMARY BACKGROUND DATA

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For non-complex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

METHODS

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

RESULTS

Ninety-three studies representing 12440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% (95%CI: 2.2-4.2%, n = 11049) after minimally 12 months and 4.1%, (95%CI: 2.9-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2-6.4%, n = 4891) and 5.5% (95%CI: 4.4-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (OR: 0.27, 95%CI: 0.15-0.51, p < 0.001) and equal recurrence rates compared to intraperitoneal onlay (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03-3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8-2.8%, n = 982), albeit based on non-randomized studies.

CONCLUSIONS

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except surgical site infection. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

Mesh abdominoplasty for rectus diastasis in women and men

Purpose

Meshes clearly have improved outcomes for tissue approximation over suture repairs for incisional hernias. A knowledge gap exists as to the surgical complication rate and post-operative outcomes of a mesh rectus diastasis repair with a narrow well-fixed mesh that simultaneously narrows the rectus muscles and closes the widened linea alba.

Methods

Inclusion criteria for mesh abdominoplasty were patients who (1) underwent a retrorectus planar mesh for repair of rectus diastasis (2) did not have a concurrent incisional hernia and (3) underwent skin tailoring as part of a cosmetic aspect of their care. The primary endpoint was surgical site occurrence (SSO) at any time after surgery as determined with review of their office and hospital medical records. Secondary endpoints included the length and complexity of the return to the operating room for any reason, non-surgical complications, readmission, post-operative recovery, surgical site infection, recurrence/persistence of abdominal wall laxity, and soft tissue revision rates.

Results

SSO rate was 0% for the 56 patients who underwent this procedure. There were 40 women and 16 men. Superficial infections requiring oral antibiotics were required in three patients. One was a drain site erythema, one was for a superficial stitch abscess, and the third was for a mesh strip knot infection 6 months after the procedure. One patient underwent further tightening of the abdominal wall. Rates of soft tissue revision in the office for improved cosmesis were 23% in women and 6% in men.

Conclusion

Repair of rectus diastasis with a narrow well-fixed mesh and concurrent skin abdominoplasty is a well-tolerated and reliable procedure with low recurrence and low SSO in the manner described. It is a procedure that works for both female and male pattern rectus diastasis, and has become our procedure of choice for moderate and severe rectus diastasis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02461-1.

Mesh Repair of Rectus Diastasis for Abdominoplasty is Safer than Suture Plication

Concerns regarding infection, extrusion, and pain have traditionally precluded the use of mesh to treat severe rectus diastasis during abdominoplasty in the United States. We describe a mesh abdominoplasty technique, and we hypothesize that the complication rate using mesh is greater than the complication rate of suture plication.

METHODS

Inclusion criteria for mesh abdominoplasty were patients who (1) had retrorectus planar mesh for repair of rectus diastasis, (2) did not have concurrent ventral hernia, and (3) underwent skin tailoring. Patients who underwent rectus plication with suture, and met criteria 2 and 3 above were included in a sample of consecutive standard abdominoplasty patients. The primary endpoint was surgical site occurrence at any time after surgery, as determined with review of their office and hospital medical records. Secondary endpoints included surgical site infection, revision rates, postoperative course, and aesthetics assessed with their last set of office photographs.

RESULTS

Surgical site occurrence rate was 0% of the 40 patients in the mesh group and 19% of the 37 patients in the standard group (P = 0.005); rates of soft-tissue revision were 23% in the mesh group and 27% in the standard group (P = 0.84). As to aesthetics, the mesh abdominoplasty patients had mean statistically lower preoperative scores in comparison with the standard plication group (65.8 ± 11.6 versus 70.3 ± 11.4, P = 0.0013). The mesh group had a statistical improvement to 75.9 ± 12.6 (P < 0.0001), whereas the standard plication group improved to 82.5 ± 11.4 (P < 0.0001).

CONCLUSIONS

Retrorectus mesh placement in a cohort of patients with severe rectus diastasis had a complication rate lower than that seen in a cohort of patients with less severe rectus diastasis, therefore negating our original hypothesis. This was done without compromising aesthetic improvement.

Complex Open Abdominal Wall Reconstruction: Management of the Skin and Subcutaneous Tissue

Optimal skin and soft tissue management in complex open abdominal wall reconstruction is an integral element of the operation to achieve optimal outcomes. Failure to provide stable, well-vascularized soft tissue coverage over the hernia repair can jeopardize the reconstruction through association with nonhealing wounds, mesh exposure, and even possible hernia recurrence. The literature has shown that careful attention to the skin and soft tissue, especially when part of a multidisciplinary approach to complex abdominal wall reconstruction, improves patient outcomes significantly.

Theoretic and Evidence-Based Laparotomy Closure with Sutures and Meshes

The ultimate tensile strength of newly apposed tissue is the sum of the strength of the physical construct holding the tissues and the strength of biologic healing. For successful incisional hernia repair, the total strength of the repair must remain greater than the forces applied. While much work has been done to understand the science of wound healing-the ability of an open defect to contract and close-far less has been done to understand the healing of 2 newly approximated previously nonwounded surfaces held together with sutures or other implants. In this article, the elements of ultimate tensile strength on laparotomy closure as well as their progression over time will be related to clinical studies of abdominal wall closure.

Mesh sutured repairs of contaminated incisional hernias

BACKGROUND

We sought to evaluate the results of a new mesh sutured repair technique for closure of contaminated incisional hernias.

METHODS

48 patients with contaminated hernias 5 cm wide or greater by CT scan were closed with mesh sutures. Surgical site occurrence, infections, and hernia recurrence were compared to similar patient series reported in the literature.

RESULTS

Of the 48 patients, 20 had clean-contaminated wounds, 16 had contaminated wounds, and 12 were infected. 69% of the patients underwent an anterior perforator sparing components release for hernias that averaged 10.5 cm transversely (range 5 cm-25 cm). SSO occurred in 27% of patients while SSI was 19%. There were no fistulas or delayed suture sinuses. With a mean follow-up of almost 12 months, 3 midline hernias recurred (6%). In these same patients, three parastomal hernias repaired with mesh sutures failed out of 4 attempted for a total failure rate of 13%.

CONCLUSION

Mesh sutured closure represents a simplified and effective surgical strategy for contaminated midline incisional hernia repair.

Current Risk Stratification Systems Are Not Generalizable across Surgical Technique in Midline Ventral Hernia Repair

Background:

Current ventral hernia repair risk estimation tools focus on patient comorbidities with the goal of improving clinical outcomes through improved patient selection. However, their predictive value remains unproven.

Methods:

Outcomes of patients who underwent midline ventral hernia repair with retrorectus placement of mid-weight soft polypropylene mesh between 2010 and 2015 were retrospectively reviewed and compared with predicted wound-related complication risk from 3 tools in the literature: Carolinas Equation for Determining Associated Risk, the Ventral Hernia Working Group (VHWG) grade, and a modified VHWG grade.

Results:

A total of 101 patients underwent hernia repair. Mean age was 56 years and mean body mass index was 29 m/kg² (range, 18–51 m/kg²). We found no significant relationship between the risk estimated by Carolinas Equation for Determining Associated Risk (B = 1.45, P = 0.61) and actual wound-related complications. VHWG grades >1 were not statistically different with regard to rate of wound complication compared with VHWG grade 1 (grade 2: B = 0.05, P = 0.95; grade 3: B = −0.21, P = 0.86; grade 4: B = 2.57, P = 0.10). Modified VHWG grades >1 were not statistically different with regard to rate of wound complication compared with modified VHWG grade 1 (grade 2: B = 0.20, P = 0.80; grade 3: B = 1.03, P = 0.41).

Conclusions:

Current risk stratification tools overemphasize patient factors, ignoring the importance of technique in minimizing complications and recurrence. We attribute our low complication rate to retrorectus placement of a narrow, macroporous polypropylene mesh with up to 45 suture fixation points for force distribution in contrast to current strategies that employ wide meshes with minimal fixation.