An Evidence-Based Model for the Successful Treatment of Flank and Lateral Abdominal Wall Hernias:

Open repair of flank and lumbar hernias: 142 consecutive repairs at a high-volume hernia center

BACKGROUND

Flank and lumbar hernias (FLH) are challenging to repair. This study aimed to establish a reproducible management strategy and analyze elective flank and lumbar repair (FLHR) outcomes from a single institution.

METHODS

A prospective analysis using a hernia-specific database was performed examining patients undergoing open FLHR between 2004 and 2021. Variables included patient demographics and operative characteristics.

RESULTS

Of 142 patients, 106 presented with flank hernias, and 36 with lumbar hernias. Patients, primarily ASA Class 2 or 3, exhibited a mean age of 57.0 ​± ​13.4 years and BMI of 30.2 ​± ​5.7 ​kg/m2. Repairs predominantly utilized synthetic mesh in the preperitoneal space (95.1 ​%). After 29.9 ​± ​13.1 months follow-up, wound infections occurred in 8.3 ​%; hernia recurrence was 3.5 ​%. At 6 months postoperatively, 21.2 ​% of patients reported chronic pain with two-thirds of these individuals having preoperative pain.

CONCLUSIONS

Open preperitoneal FLHR provides a durable repair with low complication and hernia recurrence rates over 2.5 years of follow-up.

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes.

METHODS

We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital.

RESULTS

We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway.

CONCLUSION

In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Robotic versus open lateral abdominal hernia repair: a multicenter propensity score matched analysis of perioperative and 1-year outcomes

PURPOSE

Lateral abdominal hernias are inherently challenging surgical entities. As such, there has been an increase in the adoption of robotic platforms to approach these challenging hernias. Our study aims to assess and compare outcomes between open (oLAHR) and robotic (rLAHR) lateral abdominal hernia repair using a national hernia-specific database.

METHODS

A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative was performed to include all adult patients who underwent elective lateral hernia repair. A propensity score match analysis was conducted, and univariate analyses were conducted to compare these two surgical modalities across perioperative timeframes.

RESULTS

The database identified 2569 patients. Our analysis matched 665 patients to either the open or robotic groups. The median length of stay, surgical site occurrences (SSO), and surgical site occurrences requiring procedural interventions (SSOPI) were higher in the oLAHR versus the rLAHR group. Overall, oLAHR had a significantly higher rate of having any post-operative complications or any SSO/SSOPI. There was no difference in quality-of-life measures between groups at 30 days and 1 year.

CONCLUSION

Robotic abdominal hernia repair is a safe alternative compared to the open repair of lateral abdominal hernias with better perioperative outcomes. Despite having a longer operative time, the robotic approach can offer a significantly shorter length of stay and an overall lower rate of complications. Ultimately, there is no difference in the quality-of-life measures both at 30 days and 1 year between the open and robotic approaches.

Repair of traumatic flank hernia with mesh strip suture: a case report

Traumatic flank hernia is a relatively rare hernia. We report a case of a male patient with severe multiple trauma, including abdominal injury, who presented with flank hernia 3 years postinjury. The hernia was successfully repaired using mesh strips suture, and at the 12-month follow-up, no complications or recurrence was found. Our findings indicate that when it is difficult to secure a sufficient operative field for mesh anchoring in a traumatic flank hernia, a technique of sutured repair with mesh strips may be considered as a treatment option as it requires less dissection. Compared to the conventional planar mesh repair, this technique decreases the risk of injuries and ischemic necrosis of the surrounding tissues.

Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair

INTRODUCTION

The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes.

METHODS

A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre-optimization pathways were then compared with a recent Delphi consensus statement.

RESULTS

Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre-optimization and plan the definitive repair. These pre-optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well-defined referral criteria, perioperative high-risk management with pre-optimization, surgical planning, postoperative care and follow-up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness.

CONCLUSIONS

CAWH MDT can provide comprehensive, patient-centred care with improved postoperative outcomes. CQR are important to better evaluate long-term outcomes and ensure rigorous quality control.

ROBOTIC TRANS-ABDOMINAL PREPERITONEAL APPROACH (TAPP) APPROACH FOR LATERAL INCISIONAL HERNIAS

Background:

Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair.

Aim:

To describe a robotic assisted surgical technique for incisional lumbar hernia repair.

Methods:

Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies.

Results:

Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGrip^TM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl^® transfacial sutures, Evicel^® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days.

Conclusion:

The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.

Permanent Flank Bulge after Flank Incision: Patient- and Physician-Reported Outcome

INTRODUCTION

The aim of this study was to determine the incidence and risk factors for postoperative flank bulging and associated physiologic/psychologic consequences as well as to establish a clinical flank bulge classification system after open retroperitoneal surgery.

METHODS

In this retrospective study, a postal patient survey was sent to 240 patients who underwent open retroperitoneal surgery between 2007 and 2017. Patients, who reported a flank bulge, were invited for further evaluation, which included a clinical examination and standardized photo documentation.

RESULTS

Forty-three of 120 patients (35.8%) reported a flank bulging after retroperitoneal surgery. During clinical examination, a flank bulge could be confirmed in 25 patients, whereas in 18 patients, no bulging could be detected, leading to a corrected rate of flank bulge-positive patients of 20.8%. The corresponding relaxation values ranged from 1 to 1.44 and correlated with the clinical degree of bulging. A body mass index of ≥25 was identified as a risk factor. No correlation was found regarding age, gender, surgery side, access to the retroperitoneum, surgical procedure, and pathology. Thirty-seven patients complained about chronic pain or suffered from the cosmetic impact of bulging. Thirteen of those patients had shown a flank bulge during clinical examination, resulting in a symptomatic bulge rate of 10.8% (13/120 patients).

CONCLUSION

Chronic pain and postoperative flank bulging are 2 of the most common long-term complications after open retroperitoneal access. If an open retroperitoneal approach is required, particularly obese patients should be thoroughly informed about the risk of flank bulging and chronic pain.

Incisional Lumbodorsal Hernias Following Retroperitoneal Robotic Partial Nephrectomies for Small Renal Masses at a High-Volume Tertiary Referral Center

Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH (p = 0.545, p = 0.637). Conclusion: The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.

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.

Robotic assisted treatment of flank hernias: case series

BACKGROUND

Flank hernias are uncommon, surgical treatment is challenging and the minimally-invasive approach not always feasible. The aim of this study was to report the safety and feasibility of the robotic-assisted repair.

METHODS

The study was approved by the local ethic committee (2019-01132 CE3495). A retrospective search on a prospectively collected dataset including demographic and clinical records on robotic surgery at our institution was performed to identify patients treated for a flank hernia. Patients were followed-up 6 months.

RESULTS

From January 2018 to December 2019, out of 190 patients who underwent robotic-assisted hernia surgery, seven with incisional flank hernia were included. Median age was 69.0 years (IQR 63.2-78.0), BMI was 27.3 kg/m2 (IQR 25.8-32.3) and two patients were male (29%). All patients were referred to surgery because of pain, whereas one of them described recurrent episodes of small bowel obstruction. The median hernia defect measured 25 mm ((IQR 21-40), median mesh diameter was 10 cm (IQR 10-12.5) and median operative time was 137 min (IQR 133-174). No intraoperative complication occurred. Postoperatively, one patient developed a pneumonia, which required antibiotics. Length of hospital stay was 4.0 days (IQR 3.0-7.7). Six months after surgery, neither recurrence nor chronic pain were recorded.

CONCLUSIONS

Robotics in abdominal wall hernia surgery remains a matter of debate, despite a growing interest from the surgical community. In our reported experience with flank hernias, we found the robotic-assisted approach to be safe and feasible for the treatment of this uncommon clinical entity.

Management of lateral abdominal hernias

PURPOSE

Lateral abdominal wall hernias are rare defects but, due to their location, repair is difficult, and recurrence is common. Few studies exist to support a standard protocol for repair of these lateral hernias. We hypothesized that anchoring our repair to fixed bony structures would reduce recurrence rates.

METHODS

A retrospective review of all patients who underwent lateral hernia repair at our institution was performed.

RESULTS

Eight cases (seven flank and one thoracoabdominal) were reviewed. The median defect size was 105 cm² (range 36-625 cm²). The median operative time was 185 min (range 133-282 min). There were no major complications. One patient who was repaired without mesh attachment to bony landmarks developed a recurrence at ten months and subsequently underwent reoperation. Patients with mesh secured to bony landmarks were recurrence free at a median follow-up of 171 days.

CONCLUSIONS

Lateral hernias present a greater challenge due to their anatomic location. An open technique with mesh fixation to bony structures is a promising solution to this complex problem.

Surgical Outcomes in Lateral Abdominal Wall Reconstruction: A Comparative Analysis of Surgical Techniques

BACKGROUND

Lateral abdominal wall (LAW) myofascial defects are a challenging reconstructive problem, and no consensus exists on their surgical management. We hypothesized that mesh repairs anchored to the nonyielding LAW boundaries (pillar-anchored repairs [PARs]) would provide more durable reconstructions, with lower hernia recurrence and bulge occurrence rates, compared with mesh repairs anchored to the surrounding oblique muscle complexes (direct repairs [DRs]).

STUDY DESIGN

We retrospectively reviewed LAW reconstructions at a single center from 2004 to 2010. Patients were divided into 2 groups based on whether they had received a PAR or a DR. The primary outcome measure was hernia recurrence. The secondary outcome measures were surgical site occurrences (SSOs), surgical site infections (SSIs), and reoperations for complications.

RESULTS

We analyzed 106 consecutive patients with LAW reconstructions (PAR, 59 DR, 47). The median follow-up time was 28.1 months (PAR, 24.5 months; DR, 34.5 months). The baseline demographics were similar in the groups. Nineteen hernia recurrences were observed (PAR, 5 [8.5%]; DR, 14 [29.8%]; p = 0.033, log-rank test). The "closure type" (bridged vs reinforced repair), "mesh type" or "defect area" were not associated with hernia recurrence or bulge occurrence. The groups did not differ significantly regarding SSOs, SSIs, or reoperations for complications. In the multivariable Cox proportional regression model, PAR provided a 3.5 times lower risk of hernia recurrence than DR (adjusted hazard ratio, 0.28; 95% CI 0.09 to 0.88; p = 0.03).

CONCLUSIONS

The PAR technique is superior to DR for reconstructing LAW defects in order to achieve the lowest hernia recurrence rates in this complex patient population.

Reconstruction of the Abdominal Wall after Oncologic Resection: Defect Classification and Management Strategies

Compared with conventional ventral hernia repair, there are several additional considerations germane to the oncologic abdominal wall reconstruction, including the management of radiation soft-tissue injury, the management of bacterial contamination, and the location and extent of the defect. Herein, we review some of the unique challenges associated with oncologic abdominal wall reconstruction and introduce a new classification schema to assist the reconstructive surgeon in performing these complex cases.

Lateral Abdominal Wall Reconstruction

Lateral abdominal wall defects, while rare, present a more challenging problem than commonly encountered ventral defects due to the complexity of the anatomy, physiologic forces, and impact of muscle denervation. The lateral abdominal wall encompasses a large surface area ranging from the costal margin superiorly to the iliac crest inferiorly and from the linea semilunaris anteriorly to the paraspinous musculature posteriorly. The ratio of muscle to fascia/aponeurosis is much higher, which makes repair through muscle tissue versus fascia less secure. Furthermore, these defects are subject to asymmetric forces caused by the independent contraction of anterior and posterior muscle units, which lead to unbalanced strain and hernia progression. These features necessitate the use of wide underlay mesh load bearing repairs supported by the static pillars of the abdominal wall. Management can be further complicated when defects extend beyond the defined boundaries, requiring surgical repair to be adapted based on the border structures involved. Primary fascial coaptation may not be as easily accomplished, and therefore careful planning is important to ensure stable coverage of exposed mesh.

Lateral Abdominal Wall Defects: The Importance of Anatomy and Technique for a Successful Repair

Flank and lateral abdominal wall defects can be an extremely challenging phenomenon for surgeons to undertake. Their rarity and specific idiosyncrasies in regard to embryologic and anatomical characteristics must be taken into consideration when formulating an operative plan. We will discuss these cardinal points including technical recommendations by notable experts in the field to gain a better understanding in the diagnosis and treatment of this infrequent but morbid occurrence.