Biologic vs Synthetic Mesh for Parastomal Hernia Repair: Post Hoc Analysis of a Multicenter Randomized Controlled Trial

Elective complex ventral hernia repair in contaminated fields: A propensity score-matched analysis of long-term quality of life and outcomes between different prostheses

BACKGROUND

Randomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain.

METHODS

The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II-IV) ventral hernia repair (2013-2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh.

RESULTS

A total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53-70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12-25) and 13 cm (IQR 8-16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups.

CONCLUSION

In the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.

Robotic Pauli repair of parastomal hernia

BACKGROUND

Robotic retro-muscular mesh repair of parastomal hernia (PH) is possible with transversus abdominis release. The aim of this study is to report mid-term results with this method.

METHODS

Patients who underwent surgery for PH were enrolled in a prospective study. Patients with concomitant midline hernia also underwent Rives repair. Polypropylene meshes with an absorbable buffer mesh were used in the retro-muscular pocket-except PTFE was chosen for inflammatory bowel disease patients. Follow-up was by telephone and physical examination and CT if suspicion of complication.

RESULTS

Of the 56 included ostomy patients, 44 had colostomies, 10 had ileostomies, and two had urostomies. Thirty-nine percent had a concomitant hernia, and 25% had recurrent PH. The mean operating time without accessory repair was 156 min (SD 37), and with accessory repairs 220 min (SD 62). One bowel lesion and one vascular injury to the stoma occurred, prompting intraoperative stoma revision without postoperative morbidity. Postoperative complications ensued in 12 patients (23%). One patient had stoma necrosis after 3 weeks and the stoma was relocated. One patient had a mesh infection, 3 patients temporary ileus, one patient hypovolemic renal failure, and two patients experienced a flare-up of their Crohn's Disease. One parastomal abscess was drained percutaneously. The median postoperative stay was 3 days (1-21; mean 3.7 days), and the readmission rate was 8.9%. The recurrence rate at mean and median 24 months follow-up is 5.4%, two in ileostomy patients and one colostomy patient with unaltered bulging where CT shows a relatively large prolapse and recorded as a failure.

CONCLUSION

Robotic Pauli repair has shown promising results. However, repair fails of PH at small bowel ostomies with short mesentery. ePauli/TAR is now the preliminary choice for eligible patients at our site. Comparative studies with the intraperitoneal mesh standard are needed.

Open Retromuscular Sugarbaker vs Keyhole Mesh Placement for Parastomal Hernia Repair: A Randomized Clinical Trial

Importance

Durable parastomal hernia repair remains elusive. There is limited evidence comparing the durability of the open retromuscular Sugarbaker and keyhole mesh configurations.

Objective

To determine if the open retromuscular Sugarbaker mesh placement technique would lower parastomal hernia recurrence rates.

Design, Setting, and Participants

In this single-center, randomized clinical trial, 150 patients with a permanent stoma and associated parastomal hernia who were candidates for open retromuscular parastomal hernia repair were enrolled and randomized from April 2019 to April 2022 and followed up for 2 years.

Interventions

Following intraoperative assessment to determine the feasibility of either technique, enrolled patients were randomized to receive either retromuscular Sugarbaker or keyhole synthetic mesh placement.

Main Outcomes and Measures

The primary outcome was parastomal hernia recurrence at 2 years. Secondary outcomes included mesh-related complications, wound complications, reoperations, as well as patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at 1 year and 2 years.

Results

A total of 150 patients were randomized, and with 91% follow-up at 2 years, there were 13 (17%) parastomal hernia recurrences in the retromuscular Sugarbaker arm and 18 (24%) in the keyhole arm (adjusted risk difference, -0.029; 95% CI, -0.17 to 0.153, and adjusted risk ratio, 0.87; 95% CI, 0.42 to 1.69). There were no statistically significant differences between the Sugarbaker and keyhole groups regarding reoperations for recurrence (2 vs 7, respectively), nonhernia intra-abdominal pathology (4 vs 10, respectively), stoma necrosis (1 vs 0, respectively), mesh-related complications (4 vs 1, respectively), patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at any time point.

Conclusions and Relevance

In the setting of open parastomal hernia repair, a retromuscular Sugarbaker mesh placement technique was not superior to a keyhole configuration 2 years after repair. Further innovation is necessary to improve parastomal hernia repair outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03972553.

Comparison of the 3-D mesh and Sugarbaker repair for parastomal hernia: a single center experience in China

Parastomal hernias (PSH) are difficult to manage and associated with high rates of postoperative recurrence and complications. Sugarbaker and three-dimensional (3-D) mesh repair are commonly used methods for the surgical treatment of PSH. However, the efficacy and safety of these surgical techniques have not been adequately compared. Patients with PSH who received 3-D mesh or Sugarbaker repair at our center from August 2012 to May 2023 were included. We retrospectively analyzed their demographic data and postoperative outcomes. The primary outcome measure was the recurrence rate at 1-year follow-up. A total of 86 patients were enrolled, involving 53 in the 3-D mesh (62%) group and 33 in the Sugarbaker (38%) group. Most cases (73%) involved were the laparoscopic approach. The recurrence rate at 1-year follow-up was 15% (eight cases) in the 3-D mesh group and 24% (eight cases) in the Sugarbaker group, with no statistical significance (P = 0.29). Additionally, no differences were observed between the 3-D mesh and Sugarbaker groups in the length of hospitalization or in short- and long-term complications. Sugarbaker and 3-D mesh repair have similar clinical efficacy in the surgical treatment of PSH. Further randomized controlled trials are required to confirm these results.Trial registration number.This study was retrospectively registered at clinicaltrials.gov (NCT06077318).

Parastomal hernia repair, trying to optimize the impossible reconstruction

PURPOSE

Parastomal hernias are a common and challenging problem with high rates of wound complications and hernia recurrence after repair. We present our approach to optimizing parastomal hernia repair through preoperative preparation, surgical approach, and postoperative management.

METHODS

Patients are carefully evaluated and optimized prior to surgery. Our typical surgical approach involves a generous midline laparotomy and retrorectus dissection followed by a posterior component separation with transversus abdominis release. We typically utilize a Sugarbaker technique for retromuscular mesh placement but also use the retromuscular keyhole or cruciate technique if there is insufficient bowel length.

RESULTS

Previously published results from our institution include wound complication rates of up to 16% after open retromuscular parastomal hernia repair. Stoma-specific complications, such as mesh erosion in the bowel, may be attributed to the mesh placement techniques. Hernia recurrence rates range from 11 to 30% up to 2 years postoperatively.

CONCLUSION

We prefer an open retromuscular approach with a Sugarbaker mesh configuration to treat complex parastomal hernias. However, wound morbidity and repair failure rates remain high, and additional research is needed to optimize surgical outcomes.

Reinforced tissue matrix to strengthen the abdominal wall following reversal of temporary ostomies or to treat incisional hernias

BACKGROUND

Abdominal wall deficiencies or weakness are a common complication of temporary ostomies, and incisional hernias frequently develop after colostomy or ileostomy takedown. The use of synthetic meshes to reinforce the abdominal wall has reduced hernia occurrence. Biologic meshes have also been used to enhance healing, particularly in contaminated conditions. Reinforced tissue matrices (RTMs), which include a biologic scaffold of native extracellular matrix and a synthetic component for added strength/durability, are designed to take advantage of aspects of both synthetic and biologic materials. To date, RTMs have not been reported to reinforce the abdominal wall following stoma reversal.

AIM

To evaluate the effectiveness of using an RTM to reinforce the abdominal wall at stoma takedown sites.

METHODS

Twenty-eight patients were selected with a parastomal and/or incisional hernia who had received a temporary ileostomy or colostomy for fecal diversion after rectal cancer treatment or trauma. Following hernia repair and proximal stoma closure, RTM (OviTex® 1S permanent or OviTex® LPR) was placed to reinforce the abdominal wall using a laparoscopic, robotic, or open surgical approach. Post-operative follow-up was performed at 1 month and 1 year. Hernia recurrence was determined by physical examination and, when necessary, via computed tomography scan. Secondary endpoints included length of hospital stay, time to return to work, and hospital readmissions. Evaluated complications of the wound/repair site included presence of surgical site infection, seroma, hematoma, wound dehiscence, or fistula formation.

RESULTS

The observational study cohort included 16 male and 12 female patients with average age of 58.5 years ± 16.3 years and average body mass index of 26.2 kg/m2 ± 4.1 kg/m2. Patients presented with a parastomal hernia (75.0%), incisional hernia (14.3%), or combined parastomal/incisional hernia (10.7%). Using a laparoscopic (53.6%), robotic (35.7%), or open (10.7%) technique, RTMs (OviTex® LPR: 82.1%, OviTex® 1S: 17.9%) were placed using sublay (82.1%) or intraperitoneal onlay (IPOM; 17.9%) mesh positioning. At 1-month and 1-year follow-ups, there were no hernia recurrences (0%). Average hospital stays were 2.1 d ± 1.2 d and return to work occurred at 8.3 post-operative days ± 3.0 post-operative days. Three patients (10.7%) were readmitted before the 1-month follow up due to mesh infection and/or gastrointestinal issues. Fistula and mesh infection were observed in two patients each (7.1%), leading to partial mesh removal in one patient (3.6%). There were no complications between 1 month and 1 year (0%).

CONCLUSION

RTMs were used successfully to treat parastomal and incisional hernias at ileostomy reversal, with no hernia recurrences and favorable outcomes after 1-month and 1-year.

Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial

BACKGROUND

Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days.

METHODS

This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications.

RESULTS

A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days.

CONCLUSION

Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

Robotic Retromuscular (Recurrent) Parastomal Hernia Repair (r-Pauli-Repair) With Synthetically Reinforced Biological Mesh; Technique, Early Experience, and Short-Term Follow-Up

Introduction: Parastomal hernia repair remains a challenge. We describe a robotic retromuscular non-keyhole mesh repair using a synthetically reinforced biological mesh (Ovitex) for the repair of complex and/or recurrent parastomal hernia and technical modifications we made along the way to improve our technique. Methods: All patients underwent the described retromuscular parastomal hernia repair. Data was collected in a database and a retrospective analysis was performed on direct postoperative results and early follow-up. Results: Eleven patients underwent the operation. Median follow-up was 12 months. Median LOS was 6 days. Two recurrences occurred. One patient suffered postoperative hematoma and skin necrosis, which healed completely, but did lead to a recurrence. One patient had a significant seroma, which subsided without intervention. Both recurrences were reoperated, and a local repair was performed. Conclusion: This paper is the first to describe a modified robotic Pauli repair for complex and recurrent parastomal hernia, using a synthetically reinforced biological mesh. Results are satisfying so far, especially considering the complexity of the cases.

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.

Parastomal Hernia Repair

Parastomal hernias (PHs) are common and contribute to significant patient morbidity. Despite 45 years of evolution, mesh-based PH repairs continue to be challenging to perform and remain associated with high rates of postoperative complications and recurrences. In this article, the authors summarize the critical factors to consider when evaluating a patient for PH repair. The authors provide an overview of the current techniques for repair, including both open and minimally invasive approaches. The authors detail the mesh-based repair options and review the evidence for choice of mesh to use for repair.

Full endoscopic minimally invasive extraperitoneal modified Sugarbaker approach for para-colostomy hernia repair: Technical aspects and 2-year follow-up results of a prospective cohort

AIM

This study aimed to assess technical aspects and clinical results of a new minimally invasive technique in parastomal hernia (PSH) repair, full endoscopic retromuscular access, after 2 years of follow-up.

METHODS

Data from consecutive patients requiring minimally invasive ventral PSH repair were collected from 2019 to 2022. The inclusion criteria were patients aged between 18 and 80 years old with symptomatic PSH. Demographics and perioperative and postoperative data were collected. Postoperative pain and functional recovery were compared with preoperative data.

RESULTS

Twelve patients with symptomatic PSH were included. The mean PSH defect area was 16.2 cm2 and the mean midline defect was 8.7 cm2 . No intra-operative complications or conversion to open surgery were detected. One patient (8%) required postoperative readmission due to partial bowel obstruction symptoms that required catheterization of the stoma. Pain significantly worsened after the first postoperative day compared to preoperative data but improved after the first postoperative month compared to the first postoperative week and after the 90th postoperative day compared to the first postoperative month, with significant differences. Significant restriction improvement was identified when 30 days after surgery data were compared to preoperative data and when the 180th postoperative day results were compared to 30 days after surgery. The average follow-up was 29 months. During the follow-up no clinical or radiological recurrence was observed.

CONCLUSION

This paper shows low rate of intra- and postoperative complications with significant improvement in terms of pain activities restriction compared to preoperatory. After 29 months follow-up, no recurrence was identified, confirming that this approach offers good mid-term results.

Keyhole Versus Sugarbaker Mesh Configuration in Parastomal Hernia Repair: A Systematic Review and Meta-analysis

BACKGROUND

Parastomal hernia repairs (PHRs) are often complex and challenging, even for experienced abdominal wall surgeons. Although the ideal therapeutic option in the setting of a parastomal hernia is to restore intestinal continuity, this is often not feasible, and numerous techniques have been described for PHR. Current guidelines recommend using mesh for elective PHR, but there is a scarcity of evidence comparing different PHR techniques. We aimed to report a meta-analysis comparing the outcomes of the "Sugarbaker" and "Keyhole" mesh configuration in PHR.

METHODS

A literature search of PubMed, Embase, Scopus, and Cochrane Library databases was performed to identify studies comparing Sugarbaker and Keyhole mesh configuration in PHR. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics.

RESULTS

A total of 3247 studies were screened, and 27 were fully reviewed. Ten studies and 632 patients were included in the meta-analysis. Three hundred five patients (48.3%) with Keyhole and 327 patients (51.7%) with Sugarbaker mesh configuration. Four hundred thirty-three patients (68.5%) underwent laparoscopic PHR with intraperitoneal onlay mesh. Sugarbaker mesh configuration was associated with lower hernia recurrence compared with Keyhole (odds ratio: 0.39; 95% CI: 0.19-0.83; P = 0.01; I2 = 46%). No differences were seen in overall complications, reoperations, stoma outlet obstruction, mesh infection, and postoperative bleeding.

CONCLUSION

PHR with Sugarbaker mesh configuration is associated with decreased hernia recurrence compared with Keyhole and had similar rates of overall complications, reoperations, stoma outlet obstruction, mesh infection, and postoperative bleeding.

AGA Clinical Practice Update on Management of Ostomies: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the management of patients with an enteral stoma.

METHODS

This CPU was commissioned and approved by the AGA Institute Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of a multidisciplinary group of authors composed of gastroenterologists, a colorectal surgeon, a wound ostomy and continence nurse, and ostomate.

Contemporary Outcomes of Elective Parastomal Hernia Repair in Older Adults

Importance

Parastomal hernia is a challenging complication following ostomy creation; however, the incidence and long-term outcomes after elective parastomal hernia repair are poorly characterized.

Objective

To describe the incidence and long-term outcomes after elective parastomal hernia repair.

Design, Setting, and Participants

Using 100% Medicare claims, a retrospective cohort study of adult patients who underwent elective parastomal hernia repair between January 1, 2007, and December 31, 2015, was performed. Logistic regression and Cox proportional hazards models were used to evaluate mortality, complications, readmission, and reoperation after surgery. Analysis took place between February and May 2022.

Exposures

Parastomal hernia repair without ostomy resiting, parastomal hernia repair with ostomy resiting, and parastomal hernia repair with ostomy reversal.

Main Outcomes and Measures

Mortality, complications, and readmission within 30 days of surgery and reoperation for recurrence (parastomal or incisional hernia repair) up to 5 years after surgery.

Results

A total of 17 625 patients underwent elective parastomal hernia repair (mean [SD] age, 73.3 [9.1] years; 10 059 female individuals [57.1%]). Overall, 7315 patients (41.5%) underwent parastomal hernia repair without ostomy resiting, 2744 (15.6%) underwent parastomal hernia repair with ostomy resiting, and 7566 (42.9%) underwent parastomal hernia repair with ostomy reversal. In the 30 days after surgery, 676 patients (3.8%) died, 7088 (40.2%) had a complication, and 1740 (9.9%) were readmitted. The overall adjusted 5-year cumulative incidence of reoperation was 21.1% and was highest for patients who underwent parastomal hernia repair with ostomy resiting (25.3% [95% CI, 25.2%-25.4%]) compared with patients who underwent parastomal hernia repair with ostomy reversal (18.8% [95% CI, 18.7%-18.8%]). Among patients whose ostomy was not reversed, the hazard of repeat parastomal hernia repair was the same for patients whose ostomy was resited vs those whose ostomy was not resited (adjusted hazard ratio, 0.93 [95% CI, 0.81-1.06]).

Conclusions and Relevance

In this study, more than 1 in 5 patients underwent another parastomal or incisional hernia repair within 5 years of surgery. Although this was lowest for patients who underwent ostomy reversal at their index operation, ostomy resiting was not superior to local repair. Understanding the long-term outcomes of this common elective operation may help inform decision-making between patients and surgeons regarding appropriate operative approach and timing of surgery.