Anatomical study comparing medialization after Rives-Stoppa, anterior component separation, and posterior component separation

Bilateral rectus muscle turning-over for complicated and eventrated abdominal wall hernias: results of a novel method

PURPOSE

We present a technique for covering large midline loss of abdominal wall using a novel method by autologous tissues.

METHODS

Twenty-two patients (body mass index = 35,6 ± 6,9 kg/m2) were involved in the prospective cohort study. Acute and elective cases were included. The gap area was 450.1 ± 54 cm2. The average width of the midline gap was 16,3 ± 3,2 cm. The rectus muscles were mobilized from its posterior sheath. Both muscles were turned by180º medially, so that the complete abdominal wall gap could be covered without considerable tension. Changes in intra-abdominal pressure, quality of life and hernia recurrency were determined.

RESULTS

There was no significant increase in the intra-abdominal pressure. Wound infection and seroma occurred in four cases. Bleeding occurred in one case. Pre- and post-operative quality of life index significantly improved (23 ± 13 vs. 47 ± 6; p = 0,0013). One recurrent hernia was registered. The procedure could be performed safely and yielded excellent results. The method was applied in acute cases. The intact anatomical structure of rectus muscles was essential.

CONCLUSIONS

The midline reconstruction with bilateral turned-over rectus muscles provided low tension abdominal wall status, and it did not require synthetic mesh implantation.

Assessment of myofascial medialization following intraoperative fascial traction (IFT) in a cadaveric model

PURPOSE

Intraoperative fascial traction (IFT) for the treatment of large ventral hernias and loss of domain (LOD) hernias is a promising tool in abdominal wall surgery. However, little is known about the extent of gain in myofascial advancement especially for the anterior rectus sheath. We, therefore, used a cadaveric model to determine the medialization during IFT.

METHODS

4 fresh frozen specimens were used. Retromuscular preparation was carried out followed by IFT with diagonal vertical traction for 30 min. Medial advancement of the anterior rectus sheath was measured after 15 and 30 min as well as traction forces.

RESULTS

Total medialization for anterior rectus sheath after 30 min of IFT was 10.5 cm (mean). The mean traction force was 16.28 kg. Total medialization was significantly higher during the first 15 min of vertical fascial traction (p < 0.05).

CONCLUSIONS

IFT provides significant medialization for the anterior rectus sheath in the cadaveric model. The findings align with results from a retrospective case study. Therefore, we see IFT as a beneficial tool in abdominal wall surgery.

Anterior versus posterior component separation technique for advanced abdominal wall reconstruction: a proposed algorithm

OBJECTIVE

The precise indications for employing the anterior component separation technique (ACST) and the Transversus Abdominis Release (TAR) in abdominal wall reconstruction (AWR) remain uncertain, despite the undeniable value of both techniques. The aim of this study was to analyze the anterior fascial closure rate, postoperative wound morbidity, and hernia recurrence rate for both procedures according to the algorithm used for complex AWR.

METHODS

A retrospective analysis of prospectively collected data was carried out. Patients undergoing AWR for midline incisional hernias using either open or endoscopic ACST (E-ACST) or TAR between March 2013 and August 2022 were included. Patients with lateral hernia components were excluded. The surgical technique was depending on the pre- and intraoperative findings regarding hernia width and on the estimated traction to achieve anterior fascial closure (see algorithm). Initially, intermediate hernia defects ranging from approximately 10-14 cm in width were repaired using E-ACST. However, as the study advanced, TAR became the preferred method for addressing these types of defects. Open ACST was consistently employed for defects wider than 14-15 cm throughout the entire study duration. Outcomes of interest were anterior fascial closure, surgical site occurrences, and hernia recurrence rate. Follow-up was performed at 1 month, 1 year, and 2 years.

RESULTS

A total of 119 patients underwent AWR with CST: 63 patients (52.9%) were included in the ACST group and 56 patients (47.1%) in the TAR group. No significant differences were observed in patient and hernia characteristics. The use of botulinum toxin A (BTA) injection and preoperative progressive pneumoperitoneum (PPP) was more frequently used in the ACST group (BTA 19.0%, PPP 15.9% versus BTA 5.4%, PPP 1.8% for TAR patients). Anterior fascial closure was achieved in 95.2% of the ACST group and 98.2% of the TAR group (p = 0.369). The TAR group demonstrated a significantly lower SSO rate at one month (44.3% versus 14.3%, p < 0.001) and required fewer procedural interventions (SSO-PI) (31.1% versus 8.9%, p = 0.003). The recurrence rate at one year was low and there was no statistically significant difference between the two groups (ACST 1.8% vs TAR 4.5%, p = 0.422).

CONCLUSION

Following a proposed algorithm, the anterior fascial closure rate was high and similar for both techniques. As postoperative wound morbidity is significantly increased after ACST, our findings support recommending TAR for defects up to 14 cm in width, while favoring open ACST for larger defects.

Five-Year Follow-Up of a Slowly Resorbable Biosynthetic P4HB Mesh (Phasix) in VHWG Grade 3 Incisional Hernia Repair

Objective

To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh.

Summary Background Data

Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12-18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce.

Methods

Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0-10].

Results

In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55-64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9-24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0-2).

Conclusions

Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index >28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection.

Morphological alterations of the abdominal wall after open incisional hernia repair with endoscopic anterior and open posterior component separation

PURPOSE

Effects of component separation (CS) on abdominal wall morphology have only been investigated in smaller case series or cadavers. This study aimed to compare abdominal wall alterations following endoscopic anterior CS (EACS) or open transverse abdominis release (TAR).

METHODS

Computed tomography scans were evaluated in patients who had undergone open incisional hernia repair with EACS or TAR. Abdominal wall circumference, lateral abdominal wall muscle thickness, and displacement were compared with (1) preoperative images after bilateral CS and (2) the undivided side postoperatively after unilateral CS.

RESULTS

In total, 105 patients were included. Fifty-five (52%) and 15 (14%) underwent bilateral and unilateral EACS, respectively. Five (5%) and 14 (13%) underwent bilateral and unilateral TAR, respectively. Sixteen (15%) underwent unilateral EACS and contralateral TAR. The external oblique and transverse abdominis muscles were significantly laterally displaced with a mean of 2.74 cm (95% CI 2.29-3.19 cm, P < 0.001) and 0.82 cm (0.07-1.57 cm, P = 0.032) after EACS and TAR, respectively. The combined thickness of the lateral muscles was significantly decreased after EACS (mean decrease 10.5% (5.8-15.6%, P < 0.001)) and insignificantly decreased after TAR (mean decrease 2.6% (- 4.8 to 9.5%, P = 0.50)). The abdominal wall circumference was unchanged after bilateral (mean reduction 0.90 cm (- 0.77 to 2.58 cm), P = 0.29) and unilateral CS (mean increase 0.03 cm (- 1.01 to 1.08 cm), P = 0.95).

CONCLUSION

Postoperative changes in the lateral abdominal wall musculature were different following EACS and open TAR. Either technique seems not to compromise the overall integrity of the lateral abdominal wall.

Minimally Invasive Tensiometry: A New Modality for Per-Operative Measurement of Medialization and Tension During Laparoscopic Hernia Surgery

Background: Newly developed techniques for minimally invasive abdominal wall reconstruction (AWR) for complex ventral hernia are continuously evolving. In order to achieve hernia defect closure, the aponeurotic edges of the hernia defect need to be approximated. Currently, surgeons have no way to objectively measure and quantify the traction required to approximate these edges. This study presents minimally invasive tensiometry (MINT), a novel technology for measuring fascial tension, as well as initial experiences and results using it. Methods: The MINT device was designed using rapid prototyping principles. It was designed as an add-on tool for any existing laparoscopic instrument, enabling objective assessment of abdominal wall tension by the use of a manually operated linear spring. Pre-clinical measurements of medialization at 10 and 20 N of tension during AWR were performed on fresh-frozen Post-Mortem Human Specimens (PMHS). Results: Three specimens were included, and a total number of 36 measurements of medialization at three different levels of the abdominal wall were performed under structured and similar circumstances. Median total medialization with 20 Newton (N) of applied tension was 25 mm (mm) cranially, 37.5 mm at the umbilicus and 27.5 mm at the caudal level. The highest rate of medialization was seen at the umbilical level (2.25 mm/N). Conclusion: MINT is a novel non-invasive technique, which allows surgeons to intraoperatively measure fascial tension when performing AWR. The MINT device is easy to use and reproduce. The next step is to start performing clinical measurements applying MINT during AWR.

EVOLUTION OF COMPONENT SEPARATION TECHNIQUE (REVIEW)

The problem of treatment of incisional ventral hernias is currently very relevant. The appearance of a hernial defect in the area of a previous operation is one of the most frequent long-term complications of any surgical treatment. Component separation techniques are the most modern and promising methods for the treatment of large ventral hernias. The review focuses on the main stages in the development of separation technique, as well as the results of treating patients with incisional ventral hernias using various options for posterior separation repair, which are currently frequently used. It has been established that posterior component separation is an effective and safe method of treatment, however, there is currently insufficient data on the long-term postoperative period and patients quality of life.

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.

A retrospective comparison of outcomes after open anterior and posterior component separation by a single surgical team

PURPOSE

While both anterior and posterior component separation techniques aid the repair of large ventral hernias, their outcomes can be remarkably dissimilar in terms of wound morbidity. We describe outcomes after open component separation by a single surgical team over the entire breadth of our experience.

METHODS

We queried a prospectively maintained database for ventral hernias who received an open bilateral component separation between January 2014 and January 2020. A retrospective review was performed to analyze patient demographics, perioperative events, adverse outcomes, and recurrence.

RESULTS

One hundred twenty-seven patients met the inclusion criteria of which 44 underwent anterior component separation (ACS) and 83 underwent posterior component separation (PCS). The two groups were broadly similar in terms of demographic and hernia-related variables. Mesh:defect area ratios, operative time, and estimated intraoperative blood loss were higher in the PCS group. The ACS group had more frequent use of drains which remained in situ for longer, along with a longer hospital stay. Surgical site occurrences (SSOs), including those needing procedural intervention (SSOPIs) were significantly more common after ACS. This group was also more likely to undergo a reoperation within 30 days of index repair. A single recurrence was noted in the ACS group after a mean follow-up duration of 43 months.

CONCLUSIONS

Open PCS may be more technically demanding than ACS, but it has a lower risk of postoperative morbidity and reoperation. While we now utilize PCS more frequently in our practice, ACS remains an important tool in our armamentarium.

Robotic hernia repair III. English version : Robotic incisional hernia repair with transversus abdominis release (r‑TAR). Video report and results of a cohort study

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aCS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pCS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pCS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

[Robotic hernia repair : Part III: Robotic incisional hernia repair with transversus abdominis release (r-TAR). Video report and results of a cohort study]

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aKS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pKS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pKS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

Component separation and large incisional hernia: predictive factors of recurrence

PURPOSE

To clarify the factors related to recurrence after component separation technique (CST).

MATERIALS AND METHODS

A retrospective study was conducted of 381 patients who underwent CST between May 2006 and May 2017 at a tertiary center. All patients had a transverse hernia defect grade W3 in EHS classification. Recurrence rate was determined by clinical examination plus confirmation by abdominal CT scan.

RESULTS

At a median of 61.6 months of postoperative follow-up, we reported 34 cases of hernia recurrence (8.9%). On multivariate analysis, BMI > 30 (OR 2.20; CI 1.10-3.91, p = 0.031), immunosuppressive drug use (OR 1.06 CI 1.48-2.75, p = 0.003) and development of surgical site infection (OR 2.7; CI 1.53-4.01, p = 0.002) were factors of recurrence after CST. There was no difference in recurrence rate among repairs of primary and recurrent hernias, urgent repair, operative time, type of prosthesis, or concomitant procedures, even planned or unplanned enterotomies.

CONCLUSION

Obesity (BMI > 30), immunosuppressive drug use, and postoperative wound infections were predictors of recurrence after CST.

Medialization after combined anterior and posterior component separation in giant incisional hernia surgery, an anatomical study

BACKGROUND

To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation is often performed. In patients with an extreme diameter hernia, anterior component separation and posterior component separation may be combined. The aim of this study was to assess the additional medialization after simultaneous anterior component separation and posterior component separation.

METHODS

Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Medialization was measured at 3 reference points.

RESULTS

Anterior component separation provided most medialization for the anterior rectus sheath, posterior component separation provided most medialization for the posterior rectus sheath. After combined component separation techniques total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional posterior component separation after anterior component separation provided 15% to 16%, and additional anterior component separation after posterior component separation provided 32% to 38% of the total medialization after combined component separation techniques. For the posterior rectus sheath, additional posterior component separation after anterior component separation provided 50% to 59%, and additional anterior component separation after posterior component separation provided 11% to 17% of the total medialization after combined component separation techniques. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization.

CONCLUSION

Anterior component separation provided most medialization of the anterior rectus sheath and posterior component separation provided most medialization of the posterior rectus sheath. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks.

Botulinum Toxin in the Surgical Treatment of Complex Abdominal Hernias: A Surgical Anatomy Approach, Current Evidence and Outcomes

BACKGROUND/AIM

Abdominal wall hernias represent a common problem in surgical practice. A significant proportion of them entails large defects, often difficult to primarily close without advanced techniques. Injection of botulinum toxin preoperatively at specific points targeting lateral abdominal wall musculature has been recently introduced as an adjunct in achieving primary fascia closure rates.

MATERIALS AND METHODS

A literature search was conducted investigating the role of botulinum toxin in abdominal wall reconstruction focusing on anatomic repair of hernia defects.

RESULTS

Injecting botulinum toxin preoperatively achieved chemical short-term paralysis of the lateral abdominal wall muscles, enabling a tension-free closure of the midline, which according to anatomic and clinical studies should be the goal of hernia repair. No significant complications from botulinum injections for complex hernias were reported.

CONCLUSION

Botulinum is a significant adjunct to complex abdominal wall reconstruction. Further studies are needed to standardize protocols and create more evidence.

Ventral Hernia Management in Obese Patients

Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.

Outcomes of Incisional Hernia Repair Surgery After Multiple Re-recurrences: A Propensity Score Matched Analysis

Background

Patients with a re-recurrent hernia may account for up to 20% of all incisional hernia (IH) patients. IH repair in this population may be complex due to an altered anatomical and biological situation as a result of previous procedures and outcomes of IH repair in this population have not been thoroughly assessed. This study aims to assess outcomes of IH repair by dedicated hernia surgeons in patients who have already had two or more re-recurrences.

Methods

A propensity score matched analysis was performed using a registry-based, prospective cohort. Patients who underwent IH repair after ≥ 2 re-recurrences operated between 2011 and 2018 and who fulfilled 1 year follow-up visit were included. Patients with similar follow-up who underwent primary IH repair were propensity score matched (1:3) and served as control group. Patient baseline characteristics, surgical and functional outcomes were analyzed and compared between both groups.

Results

Seventy-three patients operated on after ≥ 2 IH re-recurrences were matched to 219 patients undergoing primary IH repair. After propensity score matching, no significant differences in patient baseline characteristics were present between groups. The incidence of re-recurrence was similar between groups (≥ 2 re-recurrences: 25% versus control 24%, p = 0.811). The incidence of complications, as well as long-term pain, was similar between both groups.

Conclusion

IH repair in patients who have experienced multiple re-recurrences results in outcomes comparable to patients operated for a primary IH with a similar risk profile. Further surgery in patients who have already experienced multiple hernia re-recurrences is justifiable when performed by a dedicated hernia surgeon.

Supplementary Information

The online version of this article (10.1007/s00268-021-05952-5) contains supplementary material, which is available to authorized users.

Implementing preoperative Botulinum toxin A and progressive pneumoperitoneum through the use of an algorithm in giant ventral hernia repair

BACKGROUND

Repair of large ventral hernias with loss of domain can be facilitated by preoperative Botulinum toxin A (BTA) injections and preoperative progressive pneumoperitoneum (PPP). The aim of this study is to evaluate the outcomes of ventral hernioplasty using a standardized algorithm, including component separation techniques, preoperative BTA and PPP.

METHODS

All patients between June 2014 and August 2018 with giant hernias (either primary or incisional) of more than 12 cm width were treated according to a previously developed standardized algorithm. Retrospective data analysis from a prospectively collected dataset was performed. The primary outcome was closure of the anterior fascia. Secondary outcomes included complications related to the preoperative treatment, postoperative complications, and recurrences.

RESULTS

Twenty-three patients were included. Median age was 65 years (range 28-77) and median BMI was 31.4 (range 22.7-38.0 kg/m²). The median loss of domain was 29% (range 12-226%). For the primary and secondary endpoints, 22 patients were analyzed. Primary closure of the anterior fascia was possible in 82% of all patients. After a median follow-up of 19.5 months (range 10-60 months), 3 patients (14%) developed a hernia recurrence and 16 patients (73%) developed 23 surgical site occurrences, most of which were surgical site infections (54.5%).

CONCLUSION

Our algorithm using both anterior or posterior component separation, together with preoperative BTA injections and PPP, achieved an acceptable fascial closure rate. Further studies are needed to explore the individual potential of BTA injections and PPP, and to research whether these methods can prevent the need for component separation, as postoperative wound morbidity remains high in our study.