Ventral Hernia Repair: A Meta-Analysis of Randomized Controlled Trials

A comparative study between ETEP vs. IPOM repair for ventral hernia

BACKGROUND

Enhanced View Totally Extraperitoneal (eTEP) and Intraperitoneal Onlay Mesh (IPOM) are two widely performed laparoscopic approaches for ventral hernia repair. This randomized prospective study aimed to compare these two techniques in terms of various clinical outcomes.

MATERIALS AND METHODS

A total of 60 patients presenting with ventral hernias at our hospital between June 2022 and December 2023 were included in the study. All patients were fit for general anesthesia and were randomized into two groups, with 30 patients undergoing eTEP and 30 patients undergoing IPOM.

RESULTS

There were no significant differences in baseline characteristics such as age, sex, or comorbidities between the two groups. The operative time for eTEP was significantly longer, with a mean duration of 211 min compared to 177.5 min for IPOM (p < 0.001). Postoperative pain and analgesic requirements were significantly lower in the eTEP group. Two patients in the eTEP group required conversion to IPOM. No intraoperative complications occurred in either group. Two patients developed seromas on the seventh postoperative day, both of which were managed conservatively. The mean hospital stay was shorter for eTEP (3.43 days) compared to IPOM (6.16 days, p < 0.001). Patients undergoing eTEP had an earlier return to work and reported better abdominal wall quality of life. No recurrences were observed in either group during the six-month follow-up period.

CONCLUSION

eTEP repair for ventral hernias offers several advantages over the commonly performed IPOM technique, including reduced postoperative pain, shorter hospital stay, and faster recovery. However, the choice of procedure should be guided by the surgeon's expertise and confidence in performing either technique.

Clinical Characteristics and Risk Factors of Surgical Site Infection in Patients with Open Abdomen with Fistula Undergoing the Abdominal Wall Reconstruction Utilizing Biological Mesh: A Single-Center Retrospective Study

Objective: This study aimed to evaluate the clinical characteristics and identify risk factors for surgical site infection (SSI) following abdominal wall reconstruction using biological mesh. Methods: A retrospective analysis was conducted on patients with open abdomen (OA) with fistula who underwent abdominal wall reconstruction with biological mesh at Jinling Hospital between January 2010 and August 2023. Patients were divided into SSI and non-SSI groups, and their perioperative data were compared to identify potential risk factors. Results: The SSI rate following abdominal wall reconstruction was 23.71% (23/97) in patients with OA with fistula. Significant differences (p < 0.05) were found between the SSI and non-SSI groups in body mass index (BMI), BMI classification, nutritional risk index (NRI) classification, abdominal wall defect partition, pre-operative day one neutrophil count (NEUT), post-perative day one white blood cells (WBCs) and NEUT, post-operative day three WBCs and NEUT, post-operative day seven procalcitonin (PCT) and NEUT, length of hospitalization, and total hospitalization cost. Multifactorial analysis identified normal BMI (odds ratio [OR]: 0.151, 95% confidence interval [CI]: 0.041-0.551, p = 0.004) and high BMI (OR: 0.072, 95% CI: 0.010-0.546, p = 0.011) as protective factors against SSI and moderate NRI (OR: 4.054, 95% CI: 1.069-15.376, p = 0.004), severe NRI (OR: 18.233, 95% CI: 2.971-111.897, p = 0.002), and abdominal wall defect partition (OR: 4.032, 95% CI: 1.218-13.349, p = 0.022) as independent risk factors for SSI. Conclusions: Normal BMI and high BMI act as protective factors against SSI, whereas moderate NRI, severe NRI, and abdominal wall defect partition are independent risk factors for SSI. Nutritional management and surgical care should be emphasized to reduce SSI incidence in patients with OA with fistula undergoing abdominal wall reconstruction.

Retrorectus Ventral Hernia Repair Utilizing T-line Hernia Mesh: Technical Descriptions

The T-line hernia mesh is a synthetic, polypropylene mesh with mesh suture extensions designed to prevent anchor point failure by evenly distributing tension across the soft tissue. Previous studies have demonstrated the success of onlay ventral hernia repair with T-line hernia mesh, but retrorectus applications of the mesh have not yet been characterized. This technique article illustrates technical descriptions and clinical applications of the T-line hernia mesh in the retrorectus plane.

Long-term results with biosynthetic absorbable P4HB mesh in ventral abdominal wall repair: a multicentre analysis

BACKGROUND

The aim of this multicentre study was to analyse the outcomes of biosynthetic absorbable poly-4-hydroxybutyrate (P4HB) prosthesis implantation in patients undergoing ventral hernia repair (VHR) in the context of different degrees of contamination.

METHODS

From May 2016 to December 2021, a multicentre retrospective analysis of patients who underwent elective or urgent hernia repair with P4HB prosthesis was performed in seven hospitals in Spain and Portugal. Patients with a postoperative follow-up of less than 20 months and those within the theoretical period of prosthesis resorption were excluded from the study. Regarding the degree of contamination, patients were assessed according to the modified Ventral Hernia Working Group (VHWG) classification. Epidemiological data, hernia characteristics, surgical and postoperative variables (Clavien-Dindo classification) of these patients were analyzed. Risk factors related to long-term recurrence were studied by a multivariate analysis.

RESULTS

In 236 cases of P4HB prosthesis implantation, repair in cases of Grade 3 was the most frequent (49.1%), followed by Grade 2 in 42.3% of cases and Grade 1 in 8.4%. The most frequent complications were Grade 1, with the majority occurring during the first year. The overall rate of surgical site occurrences (SSO) was 30%. The hernia recurrence rate was 14.4% (n = 34), with a mean postoperative follow-up time of 41 months (22-61). The multivariate analysis showed that the onlay location of the mesh (OR 1.07; CI 1.42-2.70, p = 0.004) was a significant independent risk factor for recurrence.

CONCLUSIONS

The use of a P4HB bioresorbable mesh for the VHR with different degrees of contamination leads to favourable results overall, with an acceptable rate of hernia recurrence. The onlay location of the P4HB prosthesis is the main factor in recurrence in both elective and emergency settings.

Sequential surgeries following transversus abdominis release for abdominal wall reconstruction: Insights from a single-center analysis

INTRODUCTION

Abdominal surgery following transversus abdominis release (TAR) procedure commonly involves incisions through the previously implanted mesh, potentially creating vulnerabilities for hernia recurrence. Despite the popularity of the TAR procedure, current literature regarding post-AWR surgeries is limited. This study aims to reveal the incidence and outcomes of post-TAR non-hernia-related abdominal surgeries of any kind.

METHODS

Adult patients who underwent non-hernia-related abdominal surgery following ventral hernia repair with concurrent TAR procedure and permanent synthetic mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and January 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, and long-term hernia recurrence.

RESULTS

A total of 1137 patients who underwent TAR procedure were identified, with 53 patients (4.7%) undergoing subsequent non-hernia-related abdominal surgery post-TAR. Small bowel obstruction was the primary indication for reoperation (22.6%), and bowel resection was the most frequent procedure (24.5%). 49.1% of the patients required urgent or emergent surgery, with the majority (70%) having open procedures. Fascia closure was achieved by absorbable sutures in 50.9%, and of the open cases, fascia closure was achieved by running sutures technique in 35.8%. 20.8% experienced SSO, the SSOPI rate was 11.3%, and 26.4% required more than a single reoperation. A total of 88.7% were available for extended follow-up, spanning 17-30 months, resulting in a 36.1% recurrent hernia diagnosis rate.

CONCLUSIONS

Abdominal surgery following TAR surgery is associated with significant comorbidities and significantly impacts hernia recurrence rates. Our study findings underscore the significance of making all efforts to minimize reoperations after TAR procedure and offers suggestions on managing the abdominal wall of these complex cases.

Long-term patient-reported outcome measures (PROMs) after primary ventral or small midline incisional hernia repair

BACKGROUND

Ventral hernia repair is a common elective surgical procedure lacking strong evidence for specific operative approaches. This study aimed to evaluate the outcomes of primary suture repair or polypropylene sandwich mesh repair for ventral hernias. The main outcome measures were the rate of hernia recurrence, and evaluation of long-term complications and patient-reported outcomes.

METHODS

This retrospective cohort study evaluated patient perceived recurrence and pain in patients who had undergone a primary ventral hernia (epigastric, supraumbilical, or umbilical) repair or small (≤20 mm) midline incisional hernia repair 10 years after the procedure. Short-term follow-up occurred up to 6 weeks after the initial operation, while long-term follow-up included patients who were reviewed clinically or interviewed via telephone at or beyond 3 years after the procedure.

RESULTS

Most (75/100, 75.0%) patients had an extra-peritoneal sandwich mesh repair. Short-term follow-up showed minimal pain and normal activities for all patients (97/97, 100%). Long-term follow-up (median 12 years [IQR 11-13]) was achieved in 95.9% (93/97) of patients with only a small number reporting a slight bulge (5/93, 5.4%) and intermittent mild discomfort (8/93, 8.6%). Nine patients (9/97, 9.3%) experienced hernia recurrence, diagnosed at a median of 26 months [interquartile range, IQR, 7-58] post-operatively.

CONCLUSIONS

These findings suggest that an open sandwich mesh technique is a safe and effective method for repairing primary ventral hernias and small midline incisional hernias and is associated with favourable long-term patient-reported outcomes.

Short-term Outcomes After Laparoscopic IPOM Versus Robot-assisted Retromuscular Repair of Small to Medium Ventral Hernias: A Nationwide Database Study

OBJECTIVE

To examine the short-term outcomes after laparoscopic intraperitoneal onlay mesh (IPOM) compared with robot-assisted retromuscular repair of small to medium-sized ventral hernia.

BACKGROUND

With the introduction of a robot-assisted approach, retromuscular mesh placement is technically more feasible compared with laparoscopic IPOM, with potential gains for the patient, including avoidance of painful mesh fixation and intraperitoneal mesh placement.

METHODS

This was a nationwide cohort study of patients undergoing either laparoscopic IPOM or robot-assisted retromuscular repair of a ventral hernia with a horizontal fascial defect <7 cm in the period 2017 to 2022, matched in a 1:2 ratio using propensity scores. Outcomes included postoperative hospital length of stay, 90-day readmission, and 90-day operative reintervention, and multivariable logistic regression analysis was performed to adjust for the relevant confounder.

RESULTS

A total of 1136 patients were included for analysis. The rate of IPOM-repaired patients hospitalized > 2 days was more than 3 times higher than after robotic retromuscular repair (17.3% vs. 4.5%, P < 0.001). The incidence of readmission within 90 days postoperatively was significantly higher after laparoscopic IPOM repair (11.6% vs. 6.7%, P =0.011). There was no difference in the incidence of patients undergoing operative intervention within the first 90 days postoperatively (laparoscopic IPOM 1.9% vs. robot-assisted retromuscular 1.3%, P =0.624).

CONCLUSIONS

For patients undergoing first-time repair of a ventral hernia, robot-assisted retromuscular repair was associated with a significantly reduced incidence of prolonged length of postoperative hospital stay and risk of 90-day readmission compared to laparoscopic IPOM.

Efficacy of prophylactic negative pressure wound therapy after open ventral hernia repair: a systematic review meta-analysis

INTRODUCTION

The susceptibility to surgical site occurrence (SSO) is high following ventral hernia repair (VHR) surgery. SSO severely increases the physical and mental burden on patients. The main purpose of this review was to analyze the efficacy of negative pressure wound therapy (NPWT) after open VHR(OVHR) and explore benefits to patients.

METHODS

The Cochrane Library, PubMed, and Embase databases were searched from the date of establishment to 15 October 2022. All randomized controlled trials and retrospective cohort studies comparing NPWT with standard dressings after OVHR were included. The Revman 5.4 software recommended by Cochrane and the STATA16 software were used in this meta-analysis.

RESULTS

Fifteen studies (involving 1666 patients) were identified and included in the meta-analysis, with 821 patients receiving NPWT. Overall, the incidence rate of SSO in the NPWT group was lower compared to the control group (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.21-0.93; I2 = 86%; P = 0.03). The occurrence rate of surgical site infection (SSI; OR = 0.51; 95% CI = 0.38-0.68, P < 0.001), wound dehiscence (OR = 0.64; 95% CI = 0. 43-0.96; P = 0.03), and hernia recurrence (OR = 0.51; 95% CI = 0.28-0.91, P = 0.02) was also lowered. There was no significant difference in seroma (OR = 0.76; 95% CI = 0.54-1.06; P = 0.11), hematoma (OR = 0.53; 95% CI = 0.25-1.11; P = 0.09), or skin necrosis (OR = 0.83; 95% CI = 0.47-1.46; P = 0.52).

CONCLUSION

NPWT can effectively decrease the occurrence of SSO, SSI wound dehiscence and hernia recurrence and should be considered following OVHR.

Fragility of Randomized Clinical Trials Using Mesh in Abdominal Wall Reconstruction

This systematic review evaluates the fragility of randomized clinical trials that used mesh in abdominal wall reconstruction.

A Review of Abdominal Meshes for Hernia Repair-Current Status and Emerging Solutions

Abdominal hernias are common issues in the clinical setting, burdening millions of patients worldwide. Associated with pain, decreased quality of life, and severe potential complications, abdominal wall hernias should be treated as soon as possible. Whether an open repair or laparoscopic surgical approach is tackled, mesh reinforcement is generally required to ensure a durable hernia repair. Over the years, numerous mesh products have been made available on the market and in clinical settings, yet each of the currently used meshes presents certain limitations that reflect on treatment outcomes. Thus, mesh development is still ongoing, and emerging solutions have reached various testing stages. In this regard, this paper aims to establish an up-to-date framework on abdominal meshes, briefly overviewing currently available solutions for hernia repair and discussing in detail the most recent advances in the field. Particularly, there are presented the developments in lightweight materials, meshes with improved attachment, antimicrobial fabrics, composite and hybrid textiles, and performant mesh designs, followed by a systematic review of recently completed clinical trials.

Biologic Versus Synthetic Mesh in Ventral Hernia Repair: Participant-Level Analysis of Two Randomized Controlled Trials at Twenty-Four to Thirty-Six Months

Background: Biologic mesh has been used increasingly in complex ventral hernia repair despite limited evidence at low risk of bias supporting its use. Patients and Methods: We performed a participant-level analysis of published randomized controlled trials (RCTs) comparing biologic to synthetic mesh with complex ventral hernia repair at 24 to 36 months. Primary outcome was major complication (composite of mesh infection, recurrence, reoperation, or death) at 24 to 36 months post-operative. Secondary outcomes included length of index hospital stay, surgical site occurrence, surgical site infection, and death. Outcomes were assessed using both frequentist and Bayesian generalized linear regression models. Results: A total of 252 patients from two RCTs were included, 126 patients randomized to the intervention arm of biologic and 126 patients to the control of synthetic mesh with median follow-up of 29 (23, 38) months. Major complication occurred in 33 (33%) patients randomized to biologic, and 39 (38%) patients randomized to synthetic mesh, (relative risk [RR] 0.91, 95% confidence interval [CI] 0.63-1.31; p value = 0.600). Bayesian analysis demonstrated that compared with synthetic mesh, biologic mesh had similar probability of major complications at 24 to 36 months post-operative. The remainder of outcomes demonstrated slight benefit with synthetic mesh as opposed to biologic mesh except for mesh infection. However, under a frequentist framework, no outcome was statistically different. Conclusions: In patients undergoing open ventral hernia repair, there was no benefit for patients receiving biologic versus synthetic mesh at 24 to 36 months post-operative.

ABVENTURE-P pilot trial of physical therapy versus standard of care following ventral hernia repair: Protocol for a randomized controlled trial

Hernia disease is one of the most common reasons patients seek surgical treatment, yet nearly 1 in 4 patients seeking ventral hernia repair in the United States suffer from chronic pain, disability, and diminished physical activity. The relationships between the anterior abdominal wall, lower back, diaphragm, and pelvic floor are critical in providing function and quality of life, yet management of hernia disease has been limited to surgical restoration of anatomy without taking into consideration the functional relationships of the abdominal core. Therefore, the primary goal of this study is to evaluate the feasibility of implementing physical therapy targeted to improving stability and function in this population. A secondary goal is to estimate whether pre-operative abdominal core function predicts responsiveness to physical therapy. This study is a registry-based randomized controlled trial (NCT05142618: Pilot Trial of Abdominal Core Rehabilitation To Improve Outcomes After Ventral Hernia Repair (ABVENTURE-P)). All participants will be randomized to one of two post-operative treatment arms: standard of care plus up to 16 sessions of physical therapy, or standard of care alone. Primary timepoints include pre-operative (baseline) and ten weeks after surgery, with intermediate or secondary timepoints 30 days, 6 months, and 1 year post-operative. At each timepoint, participants will undergo functional and patient-reported outcome testing. We will also collect data on retention rate and treatment adherence. An intention to treat approach is planned for all analyses, using all participants who were randomized and have available data at the 10-week timepoint. This is a pilot and feasibility trial, hence our goals are to establish safety and initial efficacy of the PT intervention, retention and adherence to both PT and control arms, whether pre-operative abdominal core function predicts responsiveness to PT, and to collect a large enough sample to power a future definitive multi-center randomized controlled trial.

Robotic approach in complex ventral hernias: anterior component separation technique

Open onlay ventral hernia repair is still one of the most-used surgical techniques for the repair of hernias worldwide. The robotic anterior component separation technique uses the surgeon's usual anatomical expertise on onlay mesh placement with the manipulation and advantages of minimally invasive surgery. It maintains the precepts of reestablishment the midline integrity and insertion of mesh in the preaponeurotic space, without contact with the viscera. The use of this technique is simple and quite reproducible if you compare it with other techniques. Also, the time spent in surgery does not last long.

Abdominal Wall Reconstruction with Retrorectus Self-Adhering Mesh: A Single-Center Long-Term Follow-Up

BACKGROUND

Mesh repair has been demonstrated to be superior to suture alone in ventral hernia repair. In a previous short-term pilot study, the authors found lower postoperative narcotic requirements with self-adhering mesh. The aim of this study was to follow-up on that pilot study, using long-term data.

METHODS

This is a retrospective review of a prospectively collected database. All patients who underwent ventral hernia repair with retrorectus mesh and who had at least a 12-month follow-up were reviewed. Comparisons were performed between patients who received self-adhering mesh and those who received transfascially sutured mesh, using matched-pair analysis, examining perioperative outcomes, surgical-site occurrences, and hernia recurrence/bulge.

RESULTS

Forty-two patients were included in the study, with 21 patients undergoing repair with transfascially sutured mesh and 21 patients receiving self-adhering mesh. Average length of follow-up was 1078 days. There were no significant differences between the two groups in baseline characteristics. Patients receiving self-adhering mesh had significantly shorter surgery, and a shorter hospital length of stay. They also had a tendency toward lower narcotic requirements. There were no significant differences in the rate of surgical-site occurrences, hernia recurrences, or bulge between the two groups.

CONCLUSIONS

This long-term study shows that self-adhering mesh in ventral hernia repair results in similar long-term outcomes to transfascially sutured mesh, with shorter surgery, shorter length of stay, and a tendency toward improved pain control. These findings mirror the known advantages of self-adhering mesh in inguinal hernia repair. Further research is needed to study the incidence of chronic pain and the cost-effectiveness of self-adhering mesh.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Aggressive surgery for incisional hernia with necrotizing soft tissue infection highlighting unique abdominal findings

Background

Surgery for incisional hernias with obesity can be more challenging because obesity is associated with perioperative complications. Necrotizing soft tissue infection (NSTI) is a life-threatening condition that requires aggressive surgical management. Few incisional hernias with NSTI have been reported, and the optimal strategy is undetermined.

Case Presentation

A 66-year-old obese woman had been diagnosed with incisional hernia 4 years previously but was not treated. She presented with abdominal pain that had worsened 2 weeks previously. Emergency radical surgery was carried out for an incisional hernia with NSTI. The abdominal fascia was sutured directly without mesh. Negative pressure wound therapy was performed after surgery. The postoperative course was uneventful, without recurrence.

Conclusions

Aggressive surgery is a valid strategy for life-threatening incisional hernias with NSTI. Strategies should be developed based on physiological and anatomical findings.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

S041-Trends and short-term outcomes of three approaches to minimally invasive repair of small ventral hernias. An ACHQC analysis

INTRODUCTION

Different approaches and mesh positions are used for minimally invasive ventral hernia repair (MIS-VHR). Our aim was to evaluate the trends and short-term outcomes of intraperitoneal onlay mesh (IPOM), preperitoneal, and retromuscular repairs for small ventral hernias.

METHODS

We conducted a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC). We included elective MIS-VHR in adults with hernia defect width < = 6 cm from 2012 to 2021. We compared patient/hernia characteristics, trends, and short-term outcomes between IPOM, preperitoneal, and retromuscular repairs. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics.

RESULTS

A total of 7261 patients were included (IPOM = 4484, preperitoneal = 1829, retromuscular = 948). Preperitoneal repair was associated with lower rates of incisional (preperitoneal = 37%, IPOM = 63%, retromuscular = 73%) and recurrent hernias (preperitoneal = 11%, IPOM = 21%, retromuscular = 22%) compared to IPOM and retromuscular. Median defect width was 3.0, 2.0, and 4.0 cm for IPOM, preperitoneal, and retromuscular, respectively. There has been a progressive increase in the proportion of preperitoneal and retromuscular repairs over time (10% in 2013-53% in 2021 of all MIS-VHR). Robotic approach was more frequently utilized in preperitoneal and retromuscular (both > 85%) compared to IPOM (47%). Transversus abdominis release was performed in 14% of retromuscular repairs. After IPTW, no clinically significant differences were noted in the short-term outcomes between IPOM versus preperitoneal. Retromuscular repairs were associated with higher risk of 30-day reoperation (OR = 3.54, 95%CI [1.67, 7.5] and OR = 5.29, 95%CI [1.23, 22.74]) compared to IPOM and preperitoneal repairs, respectively, and higher risk of 30-day readmission compared to preperitoneal repairs (OR = 2.6, 95%CI [2.6, 6.4]).

CONCLUSION

Based on ACHQC data, preperitoneal and retromuscular approaches for MIS-VHR of small hernias have increased over time and are primarily performed robotically. Transversus abdominis release was performed in 14% of retromuscular repairs of these small hernias. Retromuscular repairs were associated with higher 30-day readmission and reoperation rates compared to the other approaches.

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.

Umbilical hernia repair in patients with cirrhosis: who, when and how to treat

PURPOSE

Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past.

METHODS

The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia.

RESULTS

Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances.

CONCLUSION

Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial

BACKGROUND

There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life.

METHOD

This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes.

RESULTS

Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective.

CONCLUSION

eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.

Two-year Outcomes of Prehabilitation Among Obese Patients With Ventral Hernias: A Randomized Controlled Trial (NCT02365194)

OBJECTIVE

To determine if preoperative nutritional counseling and exercise (prehabilitation) improve outcomes in obese patients seeking ventral hernia repair (VHR)?

SUMMARY BACKGROUND DATA

Obesity and poor fitness are associated with complications following VHR. It is unknown if preoperative prehabilitation improves outcomes of obese patients seeking VHR.

METHODS

This is the 2-year follow-up of a blinded randomized controlled trial from 2015 to 2017 at a safety-net academic institution. Obese patients (BMI 30-40) seeking VHR were randomized to prehabilitation versus standard counseling. Elective VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was percentage of hernia-free and complication-free patients at 2 years. Complications included recurrence, reoperation, and mesh complications. Primary outcome was compared using chi-square. We hypothesize that prehabilitation in obese patients with VHR results in more hernia- and complication-free patients at 2-years.

RESULTS

Of the 118 randomized patients, 108 (91.5%) completed a median (range) follow-up of 27.3 (6.2-37.4) months. Baseline BMI (mean±SD) was similar between groups (36.8 ± 2.6 vs 37.0 ± 2.6). More patients in the prehabilitation group underwent emergency surgery (5 vs 1) or dropped out of the program (3 vs 1) compared to standard counseling (13.6% vs 3.4%, P = 0.094). Among patients who underwent surgery, there was no difference in major complications (10.2% vs 9.1%, P = 0.438). At 2-years, there was no difference in percentage of hernia-free and complication-free patients (72.9% vs 66.1%, P = 0.424, 1.14, 0.88-1.47).

CONCLUSION

There is no difference in 2-year outcomes of obese patients seeking VHR who undergo prehabilitation versus standard care. Prehabilitation may not be warranted in obese patients undergoing elective VHR.Clinical Trial Registration: This trial was registered with clinicaltrials.gov (NCT02365194).

Is prophylactic mesh closure effective to decrease the incidence of incisional hernia after laparotomy in colorectal surgery?

BACKGROUND

few studies have studied prophylactic mesh closure after laparotomy for colorectal surgery.

METHODS

a retrospective cohort study was performed to compare patients with and without prophylactic mesh closure after open colorectal surgery.

RESULTS

309 patients were included from January 2014 to December 2016. Prophylactic mesh closure was performed in 98 patients (31.7%). After a mean follow-up of 21.7 months, incisional hernia was developed in 9 and 54 patients in the group with and without mesh respectively (9.2% vs. 25.7%, OR = 0.3, p = 0.001). In the multivariate Cox model prophylactic mesh closure was associated with a protective effect on incisional hernia development with a Hazard Ratio of 0.46 (p = 0.033). Surgical site infection was more frequent in the mesh group (19.4% vs. 9.5%, OR = 2.3, p = 0.015).

CONCLUSIONS

prophylactic mesh closure is effective to decrease the incidence of incisional hernia after colorectal surgery.

Association between surgical hernia repair techniques and the incidence of seroma: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Ventral hernia repair (VHR) includes the surgical reconstruction of the abdominal wall (AW) using different surgical techniques. Although such procedures are usually devoid of complications, the formation of seroma may frequently occur. We performed a systematic review to assess the evidence from randomized controlled trials (RCTs) comparing VHR techniques and their impact on seroma formation.

METHODS

We included RCTs having seroma formation as primary endpoint. We included patients of both sexes (age > 18). For data synthesis we applied a random-effects model and calculated risk ratios (RR) with 95% confidence intervals (CI) using the Mantel-Haenszel method. Risk of bias (ROB) and publication bias were evaluated following Cochrane recommendations.

RESULTS

After database search and article screening, 21 records were included in this review. Ten RCTs compared onlay vs. sublay mesh placement techniques. Pooled analysis showed a significantly higher risk ratio for seroma in the onlay cohort (RR = 2.61, 95% CI 1.86-3.66, I² = 0, GRADE quality of evidence, moderate). Five RCTs compared laparoscopic intraperitoneal onlay mesh repair vs. open mesh placement. Pooled analysis showed that seroma formation did not differ significantly between groups (RR = 1.91, 95% CI 0.69-5.28, I² = 66%, GRADE quality of evidence, poor). High ROB was found in all studies and significant publication bias was detected in both meta-analyses.

CONCLUSION

Compared to sublay ventral hernia repair, the onlay procedure is associated with a significantly higher risk of seroma. No significant differences were observed when laparoscopic VHR was compared with the open surgical procedure. Due to the diversity of surgical techniques reported in included RCTs, it is currently not possible to draw conclusive clinical recommendations. Future studies should be standardized to provide detailed data allowing thorough evaluation of the impact of the evidence on clinical practice.

A Prospective, Single Arm, Multi-Center Study Evaluating the Clinical Outcomes of Ventral Hernias Treated with OviTex® 1S Permanent Reinforced Tissue Matrix: The BRAVO Study 12-Month Analysis

BACKGROUND

Conflicting results from previous studies have led to dissent over whether surgical mesh is safe and effective in ventral hernia repair. A newer class of mesh known as a reinforced tissue matrix, combining a biologic scaffold and minimal polymer reinforcement, offers promise in reducing inflammatory response and increasing abdominal wall support. This study sought to assess the clinical utility of a reinforced tissue matrix (OviTex) in ventral hernia repair 12 months after implantation.

METHODS

This is a prospective, single-arm, multi-center study to evaluate the clinical performance of OviTex^® 1S Permanent (OviTex) in the repair of primary or recurrent ventral hernias (VH) in consecutive patients (ClinicalTrials.gov/NCT03074474). The rate of surgical site occurrences (SSOs) was evaluated 90 days post-surgery as the primary endpoint. Hernia recurrence and the incidence of postoperative events were evaluated between three and 12 months as secondary endpoints. The incidence of other complications and patient-reported outcomes were also recorded.

RESULTS

Ninety-two (92) patients were enrolled in the study, of whom seventy-six (76) reached the 12-month follow-up. All patients were at least 18 years of age with a BMI of <40 kg/m². Hernia defects were <20 × 20 cm, classified as class I-III according to the CDC wound classification system. Of the 76 patients who reached 12-month follow-up, twenty-six (34%) had previous VH repairs and thirteen (17%) had previous surgical infection. Sixty (79%) had factors known to increase the risk of recurrence. Twenty patients (26%) experienced SSOs, with ten (13%) requiring procedural intervention. Two of the 75 patients (2.7%) experienced a recurrence.

CONCLUSIONS

The low rate of hernia recurrence and SSOs requiring intervention illustrates the potential that reinforced tissue matrices, and OviTex 1S, in particular, have to improve outcomes in VH repairs. Follow-up to 24 months is ongoing.

Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study

INTRODUCTION

The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate.

METHODS

It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification.

RESULTS

42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P = .053). The average follow up was 25.8 ± 15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P = .288).

CONCLUSIONS

According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it.

Outcomes of redo-transversus abdominis release for abdominal wall reconstruction

BACKGROUND

Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR.

STUDY DESIGN

Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life.

RESULTS

Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m². Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median  - 9.5).

CONCLUSION

Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures.

Results of a Prospective Cohort Study on Open Rives Technique of the Midline Incisional Hernia: Midline Closure and Mesh Overlap

Background. Rives repair has been traditionally used for large abdominal wall defects with good results on terms of recurrence. However, it is limited by the lateral border of the posterior rectus sheath. The objective of our study was to evaluate recurrence rate, midline closure and mesh overlap in patients operated on elective midline incisional hernia by open Rives retromuscular repair. Methods. This is a prospective observational study of 83 patients who underwent elective open Rives technique between January 2014 and December 2018. Main inclusion criteria were adults with a midline incisional hernia. Recurrence, midline closure and mesh overlap were determined. Results. At a median postoperative follow-up of 32 (5-59) months, 8 cases of recurrence were reported. Patients with recurrence had wider hernia defects (101 ± 52 mm vs 66 ± 36 mm, P = .014) and were repaired with wider meshes (191 ± 93 mm vs 137 ± 68 mm, P = .042). However, although it was not statistically significant, midline closure was lower (38% vs 59%), as well as the overlapping relationship between mesh area and hernia defect area (2.937:1 vs 3.732:1) on patients that developed a recurrence. Conclusions. Rives technique provides good mid-term results in a midline incisional hernia (10% of recurrence at 36 months), including wider hernias in the recurrent cohort. The authors believe that other techniques which allow midline closure and placement of bigger meshes should be considered, especially in those hernias classified as W3 on EuraHS classification (more than 10 cm on width size).

The Case for Onlay Biologic Mesh in Abdominal Wall Reconstruction Using Progressive Tension Suture Fixation

BACKGROUND

After many years of debate, underlay and sublay placement of mesh slowly emerged as the standard of care in abdominal wall reconstruction because of lower hernia recurrence rates. However, onlay has the advantages of being faster, less invasive, and technically easier compared with underlay and sublay. Therefore, if a similar recurrence could be achieved, then onlay should be a consideration. In this study, we present a new onlay method using multipoint progressive tension suture fixation.

METHODS

This was a retrospective chart review of patients who underwent abdominal wall reconstruction from 2012 to 2019. Inclusion criteria included onlay mesh placement and at least 1 year of follow-up. The core principles of the surgical technique are establishing myofascial continuity by component separation and reinforcing the repair with onlay mesh that is fixated with multipoint progressive tension sutures.

RESULTS

The number of patients after exclusions was 59, and the average body mass index was 32.52 ± 6.44 kg/m2. More than half (62.7%) of patients had a history of hypertension, 95% had at least 1 prior abdominal/pelvic surgery, and 61% had at least 1 prior hernia repair. Postoperative complications included 20.3% of patients requiring drainage of a fluid collection in the clinic setting, and 29.3% of patients requiring return to the operating room for any reason (including superficial wound debridement). The average defect size was 231.88 ± 195.86 cm2, the mean follow-up was 3.11 ± 1.83 years, and the recurrence rate was 5.1%.

CONCLUSIONS

We report a hernia recurrence rate of 5.1% in a high-risk population with complex defects at a mean of 3.1 years of follow-up using onlay mesh fixated with multipoint progressive tension sutures. This recurrence rate is similar to that reported for both underlay and sublay techniques. However, the onlay approach is technically easier, faster, and less invasive compared with underlay and sublay techniques, which may translate into wider reproducibility, lower costs, and improved patient safety.

Mesh in Elective Hernia Repair: 10-Year Experience with over 6,000 Patients

BACKGROUND

The use of mesh in hernia repair has faced intense scrutiny, leading patients to become fearful of its use, despite its benefits in reducing hernia recurrence. We report a single institutional experience in performing hernia repair with mesh in terms of hernia-specific outcomes, mesh-related complications, and patient-reported quality of life.

STUDY DESIGN

Patients who underwent abdominal wall hernia repair with mesh at a single institution were identified from a prospectively maintained quality database. Demographic, perioperative, and postoperative outcomes data were analyzed. Surgical Outcomes Measurements System (SOMS) and Carolinas Comfort Scale (CCS) surveys were administered pre- and postoperatively at 3 weeks, 6 months, 1, 2, and 5 years.

RESULTS

Between 2010 and 2020, a total of 6,387 patients underwent abdominal hernia repair with mesh. Inguinal hernia repairs made up the majority (65%) of the operations. Rates of mesh infection varied by hernia type, with lower rates after umbilical (0.0%) and inguinal (0.4%) repair, and highest after incisional repair (1.3%). Similarly, mesh explantation rates were low after umbilical and inguinal repair (0.0% and 0.4%, respectively) and highest after incisional repair (3.0%). Scores on all SOMS domains were significantly improved from baseline (all p < 0.05). On CCS, 2.9%, 3.3%, and 4.4% of patients reported severe or disabling symptoms postoperatively at 1, 2, and 5 years, respectively.

CONCLUSIONS

Rates of mesh-related complications vary by hernia type. A majority of patients report excellent long-term quality of life, although a relatively large percentage of patients experience severe or disabling symptoms at long-term follow-up.

Robotic-assisted onlay technique: new approach using anterior mesh positioning in ventral hernia repair-an easy way to spread robotic surgery

There is still a lot of debate about what is the best technique for ventral hernia (VH) repair surgery. Robotic-assisted procedures are an excellent alternative to overcome the technical difficulties of regular laparoscopic surgery. The onlay technique is one of the most performed surgeries worldwide in open ventral hernia surgery, and the anatomy is easily recognized by all surgeons. Introducing the robotic onlay approach, using robotic-assisted surgery to perform ventral hernia repair with a technique is usual for most surgeons. This "new" approach may change the initial concept that minimally invasive abdominal wall surgery requires specific and tedious training and can help standardize ventral hernia repair by robotic surgery and facilitate training, allowing more surgeons to perform minimally invasive abdominal wall surgery. Finally, clinical studies are needed to measure the impact of Robotot implementation in MIS ventral hernia repair and long-term results.

Totally endoscopic sublay (TES) repair for lateral abdominal wall hernias: technique and first results

BACKGROUND

The optimal surgical treatment for lateral hernias of the abdominal wall remains unclear. The presented prospective study assesses for the first time in detail the clinical value of a totally endoscopic sublay (TES) technique for the repair of these hernias.

METHODS

Twenty-four consecutive patients with a lateral abdominal wall hernia underwent TES repair. This technique is naturally combined with a transversus abdominis release maneuver to create a sufficient retromuscular/preperitoneal space that can accommodate, if necessary, a giant prosthetic mesh.

RESULTS

The operations were successful in all but one patient who required open conversion because of dense intestinal adhesion. The mean defect width was 6.7 ± 3.9 cm. The mean defect area was 78.0 ± 102.4 cm² (range 4-500 cm²). The mean mesh size used was 330.2 ± 165.4 cm² (range 108-900 cm²). The mean operative time was 170.2 ± 73.8 min (range, 60-360 min). The mean visual analog scale score for pain at rest on the first day was 2.5 (range 1-4). The average postoperative stay was 3.4 days (range 2-7 days). No serious complications (Dindo-Clavien Grade 2-4) were seen within a mean follow-up period of 13.3 months.

CONCLUSIONS

A totally endoscopic technique (TES) for the treatment of lateral hernias is described. The technique revealed to be reliable, safe and cost-effective. The first results are promising, but larger studies with longer follow-up periods are recommended to determine the real clinical value.

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Potential influencing factors on the outcome in incisional hernia repair: a registry-based multivariable analysis of 22,895 patients

INTRODUCTION

Due to the paucity of randomized controlled trials, meta-analyses of incisional hernia repair can hardly give any insights into the influence factors on the various outcome criteria. Therefore, a multivariable analysis of data from the Herniamed Registry was undertaken with the aim to define potential influencing factors for the outcome.

METHODS

Multivariable analysis of the data available for 22,895 patients with primary elective incisional hernia repair was performed to assess the confirmatory predefined potential influence factors and their association with the perioperative and 1-year follow-up outcomes. A model validation procedure was implemented using a bootstrap algorithm in order to account for the robustness of results.

RESULTS

Higher European Hernia Society (EHS) width classification, open procedure, female gender, and preoperative pain have a highly significant association with an unfavorable outcome in incisional hernia repair. Larger defect width and open operation have a highly significantly unfavorable relation to the postoperative surgical complications, general complications, and the complication-related reoperations, while female gender and preoperative pain have a highly significantly unfavorable association with the rates of pain at rest, pain on exertion, and chronic pain requiring treatment at 1-year follow-up. The recurrence rate is significantly unfavorably influenced by higher EHS width classification, higher BMI, and lateral EHS classification.

CONCLUSION

Higher EHS width classification, open procedure, female gender, higher BMI, and lateral EHS classification, as well as preoperative pain are the most important unfavorable influencing factors associated with a worse outcome in incisional hernia repair.

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.

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

BACKGROUND

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

DATA SOURCES

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

CONCLUSIONS

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

Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study

INTRODUCTION

The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate.

METHODS

It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification.

RESULTS

42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P=.053). The average follow up was 25.8±15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P=.288).

CONCLUSIONS

According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it.

Inhibition of Angiotensin Converting Enzyme Impairs Anti-staphylococcal Immune Function in a Preclinical Model of Implant Infection

Background: Evidence suggests the renin-angiotensin system (RAS) plays key immunomodulatory roles. In particular, angiotensin-converting enzyme (ACE) has been shown to play a role in antimicrobial host defense. ACE inhibitors (ACEi) and angiotensin receptor blockers (ARB) are some of the most commonly prescribed medications, especially in patients undergoing invasive surgery. Thus, the current study assessed the immunomodulatory effect of RAS-modulation in a preclinical model of implant infection.

Methods:In vitro antimicrobial effects of ACEi and ARBs were first assessed. C57BL/6J mice subsequently received either an ACEi (lisinopril; 16 mg/kg/day), an ARB (losartan; 30 mg/kg/day), or no treatment. Conditioned mice blood was then utilized to quantify respiratory burst function as well as Staphylococcus aureus Xen36 burden ex vivo in each treatment group. S. aureus infectious burden for each treatment group was then assessed in vivo using a validated mouse model of implant infection. Real-time quantitation of infectious burden via bioluminescent imaging over the course of 28 days post-procedure was assessed. Host response via monocyte and neutrophil infiltration within paraspinal and spleen tissue was quantified by immunohistochemistry for F4/80 and myeloperoxidase, respectively.

Results: Blood from mice treated with an ACEi demonstrated a decreased ability to eradicate bacteria when mixed with Xen36 as significantly higher levels of colony forming units (CFU) and biofilm formation was appreciated ex vivo (p < 0.05). Mice treated with an ACEi showed a higher infection burden in vivo at all times (p < 0.05) and significantly higher CFUs of bacteria on both implant and paraspinal tissue at the time of sacrifice (p < 0.05 for each comparison). There was also significantly decreased infiltration and respiratory burst function of immune effector cells in the ACEi group (p < 0.05).

Conclusion: ACEi, but not ARB, treatment resulted in increased S. aureus burden and impaired immune response in a preclinical model of implant infection. These results suggest that perioperative ACEi use may represent a previously unappreciated risk factor for surgical site infection. Given the relative interchangeability of ACEi and ARB from a cardiovascular standpoint, this risk factor may be modifiable.

Long-Term Outcomes of Ventral Hernia Repair: An 11-Year Follow-Up

Background: Ventral hernia repair (VHR) is one of the most common general surgery procedures; however, few studies with long-term follow-up of VHR outcomes exist.

Methods: We performed a retrospective review of VHRs performed from 2000 to 2009 at a single institution. Our primary outcome was recurrence, and secondary outcomes were reoperations and complications including seroma, hematomas, abdominal wall abscess, wound infections, and mesh infections.

Results: Our sample population (n=420; mean age 46.3±11.7 years) included 230 females (54.8%), and cases included laparoscopic (n=31; 7.5%), laparoscopic converted to open (n=7; 1.7%), and open (n=373, 90%). As compared to suture repairs, mesh repair was associated with lower rates of complications (25.7% vs 29.5%, p=0.10) and recurrence (12.8% vs 15.2%, p=0.67). Laparoscopic repairs had lower rates of complications than open repairs (25% vs 26.8%; p=0.70) but similar rates of recurrence (13.8% and 13.6%; p=0.53). After logistic regression, obesity, chronic obstructive pulmonary disease, component separation technique, and prolonged operating time (>75th percentile) were associated with increased complications.

Conclusion: Obesity is a modifiable risk factor and must be addressed in patients undergoing VHRs. Mesh repair does not increase the risk of adverse long-term outcomes and may be performed safely in patients undergoing VHR.

Robotic versus laparoscopic ventral hernia repair: multicenter, blinded randomized controlled trial

OBJECTIVE

To determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair.

DESIGN

Pragmatic, blinded randomized controlled trial.

SETTING

Multidisciplinary hernia clinics in Houston, USA.

PARTICIPANTS

124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019.

INTERVENTIONS

Robotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59).

MAIN OUTCOME MEASURES

The primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat.

RESULTS

Patients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair.

CONCLUSION

This study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03490266.

Postoperative ileus after laparoscopic primary and incisional abdominal hernia repair with intraperitoneal mesh (DynaMesh®-IPOM versus Parietex™ Composite): a single institution experience

PURPOSE

Laparoscopic primary or incisional abdominal hernia repair with intraperitoneal mesh placement is a well-accepted and safe technique. Evidence for complications however remains inconclusive, and little is known about the occurrence of postoperative ileus secondary to postoperative intra-abdominal adhesions with different types of IPOM meshes used. Therefore, we retrospectively compared the occurrence of postoperative ileus between two of the different meshes used in our center.

METHODS

Three hundred seventy-five patients who underwent ventral hernia repair with intraperitoneal mesh placement, either with a DynaMesh®-IPOM (FEG Textiltechnik mbH, Aachen, Nordrhein-Westfalen, Germany) or a Parietex™ Composite mesh (Medtronic, Minneapolis, MN, USA), at the Heilig-Hart Hospital in Lier (Antwerp, Belgium) between 2012 and 2017 were retrospectively compared with regard to the occurrence of postoperative ileus until 6 weeks postoperatively. Baseline demographics and clinical data up to 6 weeks postoperatively of the patients in the two mesh groups are provided.

RESULTS

The DynaMesh®-IPOM mesh group was associated with a significantly higher incidence of postoperative ileus compared with the Parietex™ Composite mesh group with a cutoff limit at postoperative day 1 (n = 17, 6.8% vs. n = 0, 0.0%; P = 0.003) and postoperative day 4 (n = 13, 5.2% vs. n = 0, 0.0%, P = 0.006), even with a mesh surface area of ≤ 300 cm² and when both meshes were fixated with the same method of fixation (Securestrap™) with a cutoff limit for postoperative ileus at postoperative day 1 (n = 4, 7.7% vs. n = 0, 0.0%; P = 0.013) and postoperative day 4 (n = 3, 5.8% vs. n = 0, 0.0%, P = 0.040). Of the 17 patients with a postoperative ileus, 9 (52.9%) had a suspicion of adhesive small bowel obstruction on CT scan (P = 0.033) with definitive confirmation of small bowel adhesions with the DynaMesh®-IPOM mesh at laparoscopy in 2 patients.

CONCLUSION

Our results confirm current literature available regarding postoperative ileus secondary to postoperative intra-abdominal adhesions with the DynaMesh®-IPOM mesh. However, further research with well-designed, multicenter randomized controlled studies to evaluate the use and related complications of these meshes is needed.

Use of polyvinylidene fluoride (PVDF) meshes for ventral hernia repair in emergency surgery

PURPOSE

The implantation of non-absorbable meshes is the gold standard technique for ventral hernia (VH) repairs. However, emergency surgeries are often related to contaminated/infected fields, where the implantation of prosthetic materials may not be recommendable. Our aim was to evaluate the results of polyvinylidene fluoride (PVDF) meshes used for contaminated and/or complicated VH repairs in the acute setting.

METHODS

We conducted a retrospective analysis of patients with VH who underwent emergency surgery involving PVDF meshes, in a tertiary hospital (from November 2013 to September 2019). We analyzed postoperative complications and 1-year recurrence rates. We evaluated the relationships between contamination grade, mesh placement, infectious complications, and recurrences.

RESULTS

We gathered data on 123 patients; their mean age was 62.3 years, their mean BMI was 31.1 kg/m², and their mean CeDAR index was 51.6. 96.4% of patients had a grade 2-3 ventral hernia according to the Rosen index. The mean defect width was 8 cm (IQR 2-18). 93 cases (75.6%) were described as contaminated or dirty surgeries. A PVDF mesh was placed using an IPOM technique in 56.3% of cases, and via interposition location in 39.9%. The one-month recurrence rate was 5.7% and recurrence after one year was 19.1%. The overall mortality rate was 27.6%. Risk of recurrence was related to patients with a Rosen score over 2 (p < 0.001), as well as with postoperative SSI (p = 0.045). Higher recurrence rates were not related to PVDF mesh placement.

CONCLUSION

The use of PVDF meshes for emergency VH repairs in contaminated surgeries seems safe and useful, with reasonable recurrence rates, and acceptable infectious complication rates, similar to those published in the literature.

Ventral hernia repair by totally extraperitoneal approach (VTEP): technique description and feasibility study

BACKGROUND

The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results.

METHODS

The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed.

RESULTS

98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1-50) cm² and 225 (50-500) cm², respectively. The mean operation duration was 75 (30-270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0-8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1-15) days and 11.5 (1-30) days, respectively.

CONCLUSION

Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies.

Short-term outcome after ventral hernia repair using self-gripping mesh in sublay technique - A retrospective cohort analysis

BACKGROUND

Hernia repair in sublay technique is widely accepted for ventral hernias, as it appears to be advantageous in terms of complication and recurrence rates. Self-gripping meshes are increasingly used for hernia repair with retromuscular mesh positioning. However, real-life data on the safe use in that specific indication are still lacking. The purpose of this study is the evaluation of short-term postoperative outcome of self-gripping versus conventional non-self-gripping meshes in sublay hernia repair.

MATERIALS AND METHODS

This retrospective analysis assessed patients undergoing ventral hernia repair in sublay technique between January 2011 and July 2018 at the Department of Surgery, Medical University of Vienna. 244 consecutive patients were eligible for final analysis. Patients were grouped according to the utilized mesh. Baseline characteristics and peri-as well as postoperative outcome was assessed.

RESULTS

There was no significant difference in baseline characteristics between the two groups. Median follow-up was 11 months (IQR 3-30). The overall complication rate (28.3% versus 13.7%, p = 0.005) due to an increased rate of seromas (17.3% versus 6.8%, p = 0.013) and surgical site infections (12.6% versus 4.3%, p = 0.021) was significantly higher in patients with a self-gripping mesh. Significantly more patients with a self-gripping mesh needed a surgical intervention (21.3% versus 9.4%, p = 0.011).

CONCLUSION

In sublay ventral hernia repair, the use of self-gripping meshes is associated with a higher overall complication rate and an increased rate of complication-associated surgical interventions when compared to non-self-gripping mesh placements.