Comparison of Outcome After Mesh-Only Repair, Laparoscopic Component Separation, and Open Component Separation

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field.

Component Separation Decreases Hernia Recurrence Rates in Abdominal Wall Reconstruction with Biologic Mesh

BACKGROUND

It is not clear whether mesh-reinforced anterior component separation (CS) for abdominal wall reconstruction (AWR) results in better outcomes than mesh-reinforced primary fascial closure (PFC) without CS, particularly when acellular dermal matrix is used. The authors compared outcomes of CS versus PFC repair in AWR procedures aiming to determine whether CS results in better outcomes.

METHODS

This retrospective study of prospectively collected data included 461 patients who underwent AWR with acellular dermal matrix during a 10-year period at an academic cancer center. The primary endpoint was hernia recurrence; the secondary outcome was surgical-site occurrence (SSO).

RESULTS

A total of 322 patients (69.9%) who underwent mesh-reinforced AWR with CS (AWR-CS) and 139 (30.1%) who underwent AWR with PFC (AWR-PFC) without CS were compared. AWR-PFC repairs had a higher hernia recurrence rate than AWR-CS repairs (10.8% versus 5.3%; P = 0.002) but similar overall complication (28.8% versus 31.4%; P = 0.580) and SSO (18.7% versus 25.2%; P = 0.132) rates. CS repairs experienced significantly higher wound separation (17.7% versus 7.9%; P = 0.007), fat necrosis (8.7% versus 2.9%; P = 0.027), and seroma (5.6% versus 1.4%; P = 0.047) rates than PFC repairs. The best cutoff with respect to hernia recurrence was 7.1 cm of abdominal defect width.

CONCLUSION

AWR-CS repair resulted in a lower hernia recurrence rate than AWR-PFC but, despite the additional surgery, had similar SSO rates on long-term follow-up.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Surgical and Patient-Reported Outcomes of Open Perforator-Preserving Anterior Component Separation for Ventral Hernia Repair

BACKGROUND

 Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair.

METHODS

 A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life.

RESULTS

 Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m2, respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08-0.62), which corresponds to absence or minimal symptoms.

CONCLUSION

 The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality.

Laparoscopic Ventral Hernia Repair

The laparoscopic approach to ventral hernia repair is a safe and effective approach for both elective and emergent repair. The preoperative technical considerations include assessment of incarceration and potential for extensive adhesiolysis, size of defect, and atypical hernia locations. Preoperative considerations include weight loss and lifestyle modification. There are multiple methods of fascial defect closure and mesh fixation that the surgeon may consider via a laparoscopic approach, making it adaptable to varying clinical scenarios and anatomic challenges. Compared with open repair laparoscopic repair is associated with reduced surgical wound site infection, and compared with robotic repair outcomes are similar.

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.

Minimally invasive component separation technique for large ventral hernia: which is the best choice? A systematic literature review

BACKGROUND

Aim of the present systematic review is to compare the postoperative outcomes after minimally invasive anterior and posterior component separation technique (CST), in terms of postoperative morbidity and recurrence rates.

METHODS

Nine-hundred and fifty-nine articles were identified through Pubmed database. Of these, 444 were eliminated because were duplicates between the searches. Of the remaining 515 articles, 414 were excluded after screening title and abstract. One hundred and one articles were fully analysed, and 73 articles were further excluded, finally including 28 articles. Based on the surgical technique, three groups were created: Group A, endoscopic anterior CST and closure of the abdominal midline by laparotomy; Group B, endoscopic anterior CST and closure of the abdominal midline laparoscopically or robotically; Group C, laparoscopic or robotic posterior CST with transversus abdominal muscle release (TAR).

RESULTS

In group A, B and C, 196, 120 and 236 patients were included, respectively. Surgical and medical complication rates for the three groups were 31.2% and 13.7% in group A, 15.8% and 4.1% in group B, and 17.8% and 25.4% in group C, while recurrence rate was 10.7%, 6.6% and 0.4%, respectively. Statistically significant differences were observed in terms of surgical postoperative complication rate between group A versus B (p = 0.0022) and between group A versus C (p = 0.0015) and of recurrence rate between group A versus C (p = < 0.0001) and B versus C (p = 0.0009).

CONCLUSIONS

Anterior CST with midline closure by laparotomy showed the worst results in terms of postoperative surgical complications and recurrence in comparison to the pure minimally anterior and posterior CST. Posterior CST-TAR showed lowest hospital stay and recurrence rate, although the follow-up is short. However, due to the poor quality of most of the studies, further prospective studies and randomized control trials, with wider sample size and longer follow-up are required to demonstrate which is the best surgical option.

What Do We Know About Component Separation Techniques for Abdominal Wall Hernia Repair?

Introduction

The component separation technique (CST) was introduced to abdominal wall reconstruction to treat large, complex hernias. It is very difficult to compare the published findings because of the vast number of technical modifications to CST as well as the heterogeneity of the patient population operated on with this technique.

Material and Methods

The main focus of the literature search conducted up to August 2017 in Medline and PubMed was on publications reporting comparative findings as well as on systematic reviews in order to formulate statements regarding the various CSTs.

Results

CST without mesh should no longer be performed because of too high recurrence rates. Open anterior CST has too high a surgical site occurrence rate and henceforth should only be conducted as endoscopic and perforator sparing anterior CST. Open posterior CST and posterior CST with transversus abdominis release (TAR) produce better results than open anterior CST. To date, no significant differences have been found between endoscopic anterior, perforator sparing anterior CST and posterior CST with transversus abdominis release. Robot-assisted posterior CST with TAR is the latest, very promising alternative. The systematic use of biologic meshes cannot be recommended for CST.

Conclusion

CST should always be performed with mesh as endoscopic or perforator sparing anterior or posterior CST. Robot-assisted posterior CST with TAR is the latest development.

Non-crosslinked porcine acellular dermal matrix in pediatric abdominal wall reconstruction: a case series

INTRODUCTION

The use of biologic mesh where native tissue deficiencies limit reconstructive options has been well documented in the adult population, with increasing use to address the special requirements of complex abdominal wall reconstruction. There is, however, little documented evidence as to the safety and efficacy of these products in the pediatric population.

METHODS

This retrospective case series details 5 pediatric cases of complicated abdominal hernia repair with Strattice®, a non-crosslinked porcine acellular dermal matrix. Outcomes measured include recurrence, infection, seroma formation, symptomatic bulging, and need for mesh removal. Defect size, mesh size, and history of prior abdominal operations and infection were also recorded.

RESULTS

Patients received Strattice® with an average area of 132.2 (24-250)cm² and primary closure was achieved over a mesh underlay in three (60%) patients, while the remaining required a bridging approach secondary to lateral defects. Complications included suture extrusion, requiring suture removal, hernia recurrence without bulge, noted incidentally, and seroma formation, requiring placement of drains.

DISCUSSION/CONCLUSIONS

In conclusion, the use of porcine ADM in pediatric patients appears to be potentially safe and efficacious in the context of complex abdominal wall defects, including those with substantial contamination. Our small series builds on previous reports in this difficult patient population. Although additional study, with larger subject pools, would assist in solidifying the observations seen in this and other series, initial findings suggest that porcine ADM is a valuable tool in the treatment of these complex patients.

LEVEL OF EVIDENCE

Case series: Treatment study, Level IV.

Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction

BACKGROUND

Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias.

METHODS

The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement.

RESULTS

The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations.

CONCLUSION

Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.

Outcomes following placement of non-cross-linked porcine-derived acellular dermal matrix in complex ventral hernia repair

Repair of complex ventral hernias frequently results in postoperative complications. This study assessed postoperative outcomes in a consecutive cohort of patients with ventral hernias who underwent herniorrhaphy using components separation techniques and reinforcement with non–cross-linked intact porcine-derived acellular dermal matrix (PADM) performed by a single surgeon between 2008 and 2012. Postoperative outcomes of interest included incidence of seroma, wound infection, deep-vein thrombosis, bleeding, and hernia recurrence determined via clinical examination. Of the 47 patients included in the study, 25% were classified as having Ventral Hernia Working Group grade 1 risk, 62% as grade 2, 2% as grade 3, and 11% as grade 4; 49% had undergone previous ventral hernia repair. During a mean follow-up of 31 months, 3 patients experienced hernia recurrence, and 9 experienced other postoperative complications: 4 (9%) experienced deep-vein thrombosis; 3 (6%), seroma; 2 (4%), wound infection; and 2 (4%), bleeding. The use of PADM reinforcement following components separation resulted in low rates of postoperative complications and hernia recurrence in this cohort of patients undergoing ventral hernia repair.

Quality of Life after Ventral Hernia Repair with Endoscopic Component Separation Technique

Background and Aims:

Large ventral hernias are often associated with physical, social, and health problems for the patient, and surgical repair remains a challenge. Open components separation has widely been applied to obtain closure of the midline and recently a minimally invasive technique has been introduced (endoscopic components separation). The effectiveness and safety of endoscopic components separation have been demonstrated in previous reports, whereas little is known about quality of life in these patients. With a focus on quality of life, we present the first patients from our center operated on with endoscopic components separation.

Material and Methods:

A total of 19 consecutive patients scheduled for open hernia repair with endoscopic components separation from October 2010 to June 2012 were included. All procedures included endoscopic components separation because of the hernia size. Demographic data, operative information, and postoperative complications were recorded. All patients completed two similar questionnaires regarding their function level, cosmetic satisfaction, analgesic medication, alcohol consumption, and self-estimated physical and mental health before and after the hernia repair. Patients were assessed as outpatient median 2 months and 16 months after operation for exclusion of hernia recurrence and completion of the postoperative questionnaire.

Results and Conclusions:

Operating room time was median 204 min and correlated significantly with the hernia size. A total of 21 postoperative complications occurred in 14 patients. The length of stay was median 6 days and correlated significantly with duration of the operation. Of these, 15 patients participated in late follow-up visit. Two patients experienced recurrent hernias. Postoperative function level, cosmetic satisfaction, and self-estimated physical and mental health improved significantly. Alcohol consumption was significantly reduced. Endoscopic components separation is a reliable method to repair large ventral hernias, although further studies are required to determine the exact benefits for endoscopic components separation hernia repair versus conventional hernia repair.

Nutritional management of enterocutaneous fistula: a retrospective study at a Malaysian university medical center

Enterocutaneous fistula is a challenging clinical condition with serious complications and considerable morbidity and mortality. Early nutritional support has been found to decrease these complications and to improve the clinical outcome. Location of the fistula and physiological status affect the nutrition management plan in terms of feeding route, calories, and protein requirements. This study investigated the nutritional management procedures at the Universiti Kebangsaan Malaysia Medical Center, and attempted to determine factors that affect the clinical outcome. Nutritional management was evaluated retrospectively in 22 patients with enterocutaneous fistula seen over a 5-year period. Medical records were reviewed to obtain data on nutritional status, biochemical indices, and route and tolerance of feeding. Calories and protein requirements are reported and categorized. The results show that surgery was the predominant etiology and low output fistula was the major physiological category; anatomically, the majority were ileocutaneous. The spontaneous healing rate was 14%, the total healing rate was 45%, and the mortality rate was 22%, with 14% due to fistula-associated complications. There was a significant relationship between body mass index/serum albumin levels and fistula healing; these parameters also had a significant relationship with mortality. Glutamine was used in 50% of cases; however, there was no significant relationship with fistula healing or mortality rate. The nutritional status of the patient has an important impact on the clinical outcome. Conservative management that includes nutrition support is very important in order to improve nutritional status before surgical repair of the fistula.

Predicting abdominal closure after component separation for complex ventral hernias: maximizing the use of preoperative computed tomography

BACKGROUND

Component separation techniques (CSTs) have allowed for midline fascial reapproximation in large midline ventral hernias. In certain cases, however, fascial apposition is not feasible, resulting in a bridged repair that is suboptimal. Previous estimates on myofascial advancement are based on hernia location and do not take into account variability between patients. Examination of preoperative computed tomography (CT) may provide insight into these variabilities and may allow for prediction of abdominal closure with CST.

STUDY DESIGN

A retrospective review was conducted of patients who underwent abdominal wall reconstruction from 2007 to 2012 with CST. Preoperative CT was obtained, and specific parameters were analyzed using image analysis software. Logistic regression was used to predict ideal operative closure. Multivariate analyses were adjusted for age and sex. An a priori value was set at P < 0.05.

RESULTS

Fifty-four patients met the criteria and had preoperative CT available for analysis. Forty-eight patients had fascial reapproximation achieved, whereas 6 patients had a bridged repair. Age, sex, weight, and body mass index were similar between groups (P > 0.05). Significant differences were seen between groups in 3 variables: transverse defect size (19.8 vs 10 cm, P < 0.05), defect area (420 vs 184.2 cm, P < 0.05), and percent abdominal wall defect (18.9% vs 10.6%, P < 0.05).

CONCLUSIONS

Preoperative determination of abdominal wall defect ratios and hernia defect areas may represent a more accurate method to predict abdominal wall closure after CST. Predicting midline approximation after CST is critical because outcomes after bridged repair can result in higher recurrence rates.

Complex ventral hernia repair using components separation with or without synthetic mesh: a cost-utility analysis

BACKGROUND

Components separation provides a useful option among closure choices for complex ventral hernia repairs. The use of synthetic mesh in addition to performing a components separation is controversial. The authors' goal was to perform the first cost-utility analysis on the use of synthetic mesh in addition to performing components separation when performing a complex ventral hernia repair in a noncontaminated field.

METHODS

A comprehensive literature review was conducted to identify published complication and recurrence rates for ventral hernia repairs (Ventral Hernia Workgroup I and II) requiring components separation with or without synthetic mesh. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes, Diagnosis-Related Group reimbursement codes, and expert utility estimates to fit into a decision model to evaluate the cost-effectiveness of components separation with and without synthetic mesh in reconstructing ventral hernias.

RESULTS

At average retail costs, the decision model revealed a cost increase of $541.69 and a 0.0357 increase in quality-adjusted life-years when using synthetic mesh, yielding a cost-effective incremental cost-utility ratio of $15,173.39 per quality-adjusted life-year. Univariate sensitivity analysis revealed that synthetic mesh is cost-effective when it costs less than $2049.97.

CONCLUSIONS

The addition of synthetic mesh when performing components separation in repairing complex ventral hernias is cost-effective when using average retail prices. Physicians and hospitals should use synthetic mesh in patients with noncontaminated wounds.

Component separation for complex congenital abdominal wall defects: not just for adults anymore

PURPOSE

Operative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns.

METHODS

After IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large children's hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications.

RESULTS

Nine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days-10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3-34 months).

CONCLUSION

CST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain.

Totally laparoscopic abdominal wall reconstruction: lessons learned and results of a short-term follow-up

PURPOSE

Totally Laparoscopic Abdominal Wall Reconstruction (TLAWR) combines the laparoscopic component separation and the laparoscopic ventral hernia repair, with the purpose of further increasing the benefits of a minimally invasive procedure. However, neither the patient selection criteria nor the long-term results of this technique have been reported. Our objective is to discuss our experience with five patients who received a TLAWR.

METHODS

All patients with a midline incisional hernia who underwent a TLAWR from September 2008 to October 2009 were retrospectively reviewed for early and late postoperative complications.

RESULTS

A total of five patients underwent the procedure, with a mean age of 48.6 ± 7.9 years. The mean length of stay was 9.2 ± 5.4 days, and follow-up was 12.3 ± 6.8 months. The mean defect size was 175.8 ± 56.2 cm(2). There were no early or late wound complications. Two patients had an early respiratory complication, and one patient developed a port site hernia and small bowel obstruction early after procedure, which required a re-operation. Three patients (60 %) experienced a recurrence. Possible risk factors for recurrence include previous failed hernia repair, loss of domain, large hernias and close proximity to bony structures.

CONCLUSIONS

Although TLAWR is feasible and improves wound complications, it may be associated with higher recurrence. Appropriate patient selection is imperative in order for the patient to benefit from this technique.

Surgical treatment for giant incisional hernia: a qualitative systematic review

INTRODUCTION

Repair for giant incisional hernias is a challenge due to unacceptable high morbidity and recurrence rates. Several surgical techniques are available, but all are poorly documented. This systematic review was undertaken to evaluate the existing literature on repair for giant incisional hernia.

METHODS

Literature was identified through a systematic search on PubMed, EMBASE, and CINAHL. We only included studies with clearly defined surgical techniques and defect size of at least 15 cm. The heterogeneity of the studies precluded a meta-analysis. The analysis was based on the premises of a systematic review of the literature.

RESULTS

We identified 14 studies (1,198 patients) including one randomised trial. Studies were mainly small and retrospective and highly heterogenic regarding design, outcome, inclusion, and exclusion criteria. The overall morbidity rate was median 32 % with a wide range between studies of 4-100 %. The mortality ranged from 0 to 5 % (median 0 %) and recurrence rate ranged from 0 to 53 % (median 5 %). Study follow-up ranged from 15 to 97 months (median 36 months). Mesh repair should always be used for patients undergoing repair for a giant hernia, and the sublay position may have advantages over onlay positioning. To avoid tension, it may be advisable to use a mesh in combination with a component separation technique. Inlay positioning of the mesh and repair without a mesh should be avoided.

CONCLUSIONS

Evidence to optimise repair for giant hernias is weak due to the heterogeneity and the poor quality of studies. However, sublay positioning of the mesh perhaps in combination with a component separation technique may be advantageous compared with other surgical techniques for giant hernia repair. Giant hernia repair is a challenging surgical procedure and severely lack evidence-based research from high-quality, large-scaled randomised studies.

A decade of ventral incisional hernia repairs with biologic acellular dermal matrix: what have we learned?

BACKGROUND

Innovative types of biologic mesh have provided new alternatives to ventral incisional hernia repair, especially in the face of contamination. The authors studied the experience and outcomes of patients who underwent repair of a ventral incisional hernia with biologic mesh.

METHODS

Online database and detailed reference searches were conducted. Studies chosen for review had a sample size of at least 40 patients, level IV evidence at most, and a Methodological Index for Nonrandomized Studies index of at least 10. Indications for use of biologic mesh, type of mesh, patient comorbidities, and surgical techniques were also noted.

RESULTS

Eight studies fulfilled the search criteria and included 635 patients using AlloDerm, Surgisis, and Strattice biologic tissue matrices. In one study, indications and surgical techniques were standardized, and follow-up was prospective. In the other seven studies, indications, surgical techniques, and follow-up were assessed retrospectively. The mean patient age, when reported, was 55.7 years. Body mass index ranged from 30 to 35 kg/m2 in 44 percent of the reported patients. In seven of the eight studies [565 patients (89 percent)], the mean follow-up was 25.8 months and the mean hernia recurrence rate was 21 percent. Complication rate exceeded 20 percent in most studies.

CONCLUSIONS

Biologic tissue matrices are mostly used in contaminated fields, which has allowed for a one-stage repair with no or little subsequent mesh removal. Ventral incisional hernia repair with these matrices continues to be plagued by a high recurrence rate and complications. Prospective randomized trials are needed to properly direct practice in the use of these meshes and evaluate their ultimate value.

Short- and mid-term outcome after laparoscopic repair of large incisional hernia

PURPOSE

To compare the outcome after laparoscopic incisional and ventral herniorrhaphy (LIVH) for fascial defect larger or equal than 15 cm in width with the outcome after LIVH in patients with hernia defect smaller than 15 cm.

METHODS

From 2003 through 2010, 350 patients were submitted to LIVH. In 70 cases, hernia defect was ≥15 cm in width and in 280 was <15 cm. Incisional hernias were often recurrent, double or multiorificial. In the group of larger hernias, the rate of obesity, recurrent hernia and multiorificial hernia was 27.1, 24.2 and 12.8 %, respectively, and in the group of smaller hernias 27.3, 16.1 and 2.8 %, respectively. Patients were interviewed using McGill pain score test to measure postoperative quality of life (QoL) in the mid-term.

RESULTS

LIVH for hernia ≥15 cm required longer surgical time (p = 0.034) and postoperative hospital stay (p = 0.0001). Besides, there were higher rate of postoperative prolonged ileus (p = 0.035) and polmonitis (p = 0.001). Overall recurrence rate was 2.6, 8.6 % for larger and 1.1 % for smaller incisional hernias, p = 0.045. Mc Gill pain test revealed no significant difference in the two groups of patients in postoperative QoL within 36 months.

CONCLUSIONS

Laparoscopic approach seems safe and effective even to repair large incisional hernia, the rate of recurrence was higher, but acceptable, if compared to smaller hernias. To the best of our knowledge, this is the largest reported series of incisional hernias ≥15 cm managed by laparoscopy.

Validation of a questionnaire for the assessment of pain following ventral hernia repair--the VHPQ

PURPOSE

The aim of this study was to create and evaluate the validity and reliability of a novel ventral hernia pain questionnaire (VHPQ) to assess pain following surgery for ventral hernia.

METHODS

The questionnaire was constructed using focus groups and patient interviews. Validity was tested on 51 patients who responded to the VHPQ and brief pain inventory (BPI) 1 and 4 weeks following surgery. Reliability and internal consistency was tested on 74 patients who had surgery 3 years earlier and received the VHPQ and BPI on two separate occasions. Pain not related to surgery was examined on one occasion using the VHPQ on 100 non-operated people.

RESULTS

For pain intensity items, a significant decrease was seen from week 1 to week 4 postoperative (p < 0.05). Spearman rank correlations were significant between the pain intensity items of the VHPQ and the BPI, tested 1 week postoperative (p < 0.05). Kappa levels for test-retest of items for interference with daily activities were higher than 0.5 for all items except one. Intra-class correlation was significant for pain intensity items (p < 0.05) in the test-retest group. Three years after surgery, the operated group stated more pain in the pain intensity items (p < 0.05) and more interference with daily activities (p < 0.05) than a non-operated group from the general population.

CONCLUSION

The validity and reliability of the VHPQ make it a useful tool in assessing postoperative pain and patient satisfaction.