Preservation of deep epigastric perforators during anterior component separation technique (ACST) results in equivalent wound complications compared to transversus abdominis release (TAR)

PURPOSE

The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction(AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between perforator sparing anterior component separation(PS-ACST) and transversus abdominus release(TAR).

METHODS

Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015 to 2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed.

RESULTS

A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p = 0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p < 0.001). The PS-ACST group had a larger hernia defect size (375.2 ± 156.7 vs 234.4 ± 126.9cm2, p < 0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p < 0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p = 0.129) nor was the mesh infection rate (0% vs 1.6%, p = 0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p > 0.05).

CONCLUSION

PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications.

Endoscopic Anterior Component Separation and Transversus Abdominus Release are not Associated with Increased Wound Morbidity Following Retromuscular Incisional Hernia Repair

INTRODUCTION

Traditional anterior component separation during incisional hernia repair (IHR) is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence (SSO) compared to IHR without component separation (CS).

MATERIAL AND METHOD

This was a retrospective single-center cohort study of patients undergoing open retromuscular IHR comparing patients with or without the use of CS. Retromuscular mesh repair was performed in all patients, and CS was obtained by eACS or TAR. The primary outcome was 90-day incidence of postoperative SSO. Secondary outcomes included length of stay (LOS), 90-day readmission, 90-day reoperation rate and 3-year recurrence rate.

RESULTS

A total of 321 patients underwent retromuscular repair, 168 (52.3%) of whom received either eACS or TAR. The addition of eACS or TAR was associated neither with development of SSO (odds ratio: 1.80, 95% confidence interval: 0.94-3.46, P = 0.077) nor with hernia recurrence (hazard ratio 0.77, 0.26-2.34, P = 0.648). There was no significant difference between the groups regarding the frequencies of 90-day readmission or 90-day reoperation.

CONCLUSION

eACS or TAR as adjuncts to open retromuscular IHR were not associated with increased wound morbidity or hernia recurrence.

Three-year outcome after anterior component separation repair of giant ventral hernias: A retrospective analysis of the original technique without mesh

INTRODUCTION

In this study we presented our results with anterior component separation technique utilized in the repair of giant ventral hernias. Our primary endpoints were the rates of surgical site occurrences and recurrence at three years. Besides we investigated the impact of components separation repair on abdominal wall functions.

METHODS

We retrospectively analyzed the prospectively-collected data of 40 patients that were operated on between April 2004 and February 2012 for their median ventral hernias sizing larger than 15 cm in width. Our inclusion criteria for component separation program excellently corresponded today's "giant ventral hernia" standards. The method used for components separation was identical to the original Ramirez technique, and did not comprise of any mesh reinforcement. The ICU stays, prolonged intubation, early and late complications, mortality and recurrences at three years were recorded. We used a curl-up test to demonstrate the amelioration of the abdominal wall functions postoperatively.

RESULTS

The older age and larger defect size were the significant risk factors necessitating prolonged intensive care. Surgical site occurrences were recorded in 18 patients (45.0%). A total of 7 recurrences (17.5%) were detected at three years. Patients showed a significant improvement in raising their trunks after repair (p < 0.001).

CONCLUSIONS

Our findings demonstrated that components separation technique in the original form caused excessive wound complications including skin necrosis which in turn caused delayed discharge from the hospital. The 17.5% recurrence rate seemed higher than those of more recent papers. The already-established newer modifications should be integrated in the repair method. The components separation repair clearly improves abdominal wall functions.

The use of component separation during abdominal wall reconstruction in contaminated fields: A case-control analysis

BACKGROUND

Component separation technique (CST) allows fascial medialization during abdominal wall reconstruction (AWR). Wound contamination increases the incidence of wound complications, which multiplies the incidence of repair failure. The aim of this study was to compare the impact of CST on AWR outcomes in contaminated fields in comparison to those operations without CST.

METHODS

A prospective, single institution hernia database was queried for patients undergoing AWR with CST and contamination. A case control cohort was identified using propensity score matching.

RESULTS

There were 286 CSTs performed in contaminated cases. After propensity score matching, 61 CSTs were compared to 61 No-CSTs. These groups were matched by defect area (CST:287.1 ± 150.4 vs No-CST:277.6 ± 218.4 cm², p = 0.156), BMI (32.0 ± 7.0 vs 32.2 ± 6.0 kg/m², p = 0.767), diabetes (26.2% vs 32.8%, p = 0.427), and panniculectomy (52.5% vs 36.1%, p = 0.068). Groups had similar rates of wound complications (42.6% vs 40.7%, p = 0.829) and recurrence (4.9% vs 13.1%, p = 0.114).

CONCLUSIONS

The use of CST in the face of contamination is not associated with an increase in wound complications, mesh complications, or recurrence.

A systematic methodological review of non-randomised interventional studies of elective ventral hernia repair: clear definitions and a standardised minimum dataset are needed

BACKGROUND

Ventral hernias (VHs) often recur after surgical repair and subsequent attempts at repair are especially challenging. Rigorous research to reduce recurrence is required but such studies must be well-designed and report representative and comprehensive outcomes.

OBJECTIVE

We aimed to assesses methodological quality of non-randomised interventional studies of VH repair by systematic review.

METHODS

We searched the indexed literature for non-randomised studies of interventions for VH repair, January 1995 to December 2017 inclusive. Each prospective study was coupled with a corresponding retrospective study using pre-specified criteria to provide matched, comparable groups. We applied a bespoke methodological tool for hernia trials by combining relevant items from existing published tools. Study introduction and rationale, design, participant inclusion criteria, reported outcomes, and statistical methods were assessed.

RESULTS

Fifty studies (17,608 patients) were identified: 25 prospective and 25 retrospective. Overall, prospective studies scored marginally higher than retrospective studies for methodological quality, median score 17 (IQR: 14-18) versus 15 (IQR 12-18), respectively. For the sub-categories investigated, prospective studies achieved higher median scores for their, 'introduction', 'study design' and 'participants'. Surprisingly, no study stated that a protocol had been written in advance. Only 18 (36%) studies defined a primary outcome, and only 2 studies (4%) described a power calculation. No study referenced a standardised definition for VH recurrence and detection methods for recurrence varied widely. Methodological quality did not improve with publication year or increasing journal impact factor.

CONCLUSION

Currently, non-randomised interventional studies of VH repair are methodologically poor. Clear outcome definitions and a standardised minimum dataset are needed.

A risk model and cost analysis of post-operative incisional hernia following 2,145 open hysterectomies-Defining indications and opportunities for risk reduction

BACKGROUND

Incisional hernia (IH) is a complication following open abdominal hysterectomy. This study addresses the incidence and health care cost of IH repair after open hysterectomy, and identify perioperative risk factors to create predictive risk models.

METHODS

We conduct a retrospective review of patients who underwent open hysterectomy between 2005 and 2013 at the University of Pennsylvania. The primary outcome was post-hysterectomy IH. Univariate/multivariate cox proportional hazard analyses identified perioperative risk factors. We performed cox hazard regression modeling with bootstrapped validation, risk stratification, and assessment of model performance.

RESULTS

2145 patients underwent open hysterectomy during the study period. 76 patients developed IH, and all underwent repair. 31.3% underwent reoperation, generating higher costs ($71,559 vs. $23,313, p < 0.001). 8 risk factors were included in the model, the strongest being presence of a vertical incision (HR = 3.73 [2.01-6.92]). Extreme-risk patients experienced the highest incidence of IH (22%) vs. low-risk patients (0.8%) [C-statistic = 0.82].

CONCLUSIONS

We identify perioperative risk factors for IH and provide a risk prediction instrument to accurately stratify patients in effort to offer risk reductive techniques.

SUMMARY

Open hysterectomies account for a magnitude of surgical procedures worldwide. This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2145 cases. With an increasing emphasis on prevention in healthcare, we create a risk model to improve outcomes after open hysterectomies in effort to identify high-risk patients, facilitate preoperative risk counseling, and implement evidence-based strategies to improve outcomes.

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.

Endoscopic versus open component separation: systematic review and meta-analysis

BACKGROUND

The component separation technique (CST) was developed to improve the integrity of abdominal wall reconstruction for large, complex hernias. Open CST necessitates large subcutaneous skin flaps and, therefore, is associated with significant ischemic wound complications. The minimally invasive or endoscopic component separation technique (MICST) has been suggested in preliminary studies to reduce wound complication rates post-operatively. In this study, we systematically reviewed the literature comparing open versus endoscopic component separation and performed a meta-analysis of controlled studies.

METHODS

A comprehensive search of electronic databases was completed. All English, randomized controlled trials, non-randomized comparison study, and case series were included. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias tools.

RESULTS

63 primary studies (3,055 patients) were identified; 7 controlled studies and 56 case series. The total wound complication rate was lower for MICST (20.6 %) compared to Open CST (34.6 %). MICST compared to open CST was shown to have lower rates of superficial infections (3.5 vs 8.9 %), skin dehiscence (5.3 vs 8.2 %), necrosis (2.1 vs 6.8 %), hematoma/seroma formation (4.6 vs 7.4 %), fistula tract formation (0.4 vs 1.0 %), fascial dehiscence (0.0 vs 0.4 %), and mortality (0.4 vs 0.6 %.) The open component CST did have lower rates of intra-abdominal abscess formation (3.8 vs 4.6 %) and recurrence rates (11.1 vs 15.1 %). The meta-analysis included 7 non-randomized controlled studies (387 patients). A similar suggestive overall trend was found favoring MICST, although most types of wound complications did not show to significance. MICST was associated with a significantly decreased rate of fascial dehiscence and was shown to be significantly shorter procedure.

CONCLUSION

This systematic review and meta-analysis comparing MICST to open CST suggests MICST is associated with decreased overall post-operative wound complication rates. Further prospective studies are needed to verify these findings.

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.

Open ventral hernia repair with component separation

In this article, the authors describe their current operative technique for open ventral hernia repair using component separation. Although methods of anterior component separation are described, in their current practice, the authors primarily use posterior component separation with transversus abdominis release to permit dissection beyond the retrorectus space. This method adheres to the literature-supported principles of a tension-free midline fascial closure with wide mesh overlap of mesh positioned in a sublay position. The authors' experience with this method supports a low recurrence rate and reduced wound morbidity.

Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction

Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007-2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

Evaluation of ultrasound for identification of abdominal wall myofascial components by novice learners

BACKGROUND

Minimally invasive components separation (MICS) is believed to decrease wound complications by reducing local tissue damage and eliminating the interruption of blood supply to the overlying skin and soft tissue. One drawback to the MICS technique is the difficulty with identifying the correct location for entry into the anterior abdominal wall. We believe that ultrasound can be used to visually assist identification of the correct surgical entry site (the avascular space between the external and internal abdominal oblique muscles, lateral to the linea semilunaris).

PURPOSE

The purpose of this study was to assess if novices can readily learn an ultrasound technique for identifying abdominal wall myofascial components via a video education tool.

METHODS

This research was an institutional review board-approved, prospective, observational study. Ten surgical residents were asked to watch a 1-min training video containing basic instructions on ultrasound technique for identifying the myofascial anatomy of the anterior abdominal wall. After watching the educational video, the subjects were asked to identify the linea semilunaris first by external anatomy, then by ultrasound. A grader, blinded to the identification of the subject, recorded if the subject correctly identified the location of the linea semilunaris by each method (external anatomy only versus ultrasound guided).

RESULTS

Ten subjects were evaluated. Nine of ten (90 %) subjects correctly identified the linea semilunaris with ultrasound. Only three of ten (30 %) subjects correctly identified the linea semilunaris by physical exam.

CONCLUSIONS

Ultrasound technology can aid in identification of the abdominal wall musculofascial units in MICS and be easily taught via short video instruction to novices with excellent results. Further studies will be necessary to prove that ultrasound use can decrease complications associated with entry into the appropriate avascular space between the external and internal abdominal oblique muscles, lateral to the linea semilunaris.

Abdominal wall reconstruction: a case series of ventral hernia repair using the component separation technique with biologic mesh

BACKGROUND

Sixty-eight consecutive patients from October 2008 until February 2012 were selected for this retrospective review.

METHODS

A midline fascial closure with component separation was completed using biologic mesh onlay in all cases. Recurrence rates of the hernias, complication rates, patient satisfaction, and time to return to work/normal activities were investigated.

RESULTS

The recurrence rate was 1.5% (n = 65) with ongoing follow-ups (mean = 20 months). The average age was 57 years, and the average body mass index was 36 kg/m(2) (range 22 to 60). The average hernia defect was 20 cm (range 12 to 26) transversely. Wound infection and/or breakdown occurred in 32%, and seroma formation occurred in 9% of patients. Patient satisfaction was 3.63 of 4. The average time to return to work/normal activities was 16 weeks (range 1 to 76 weeks).

CONCLUSIONS

Large complex ventral hernias can be reliably repaired using the component separation technique. The short-term recurrence rate is significantly reduced in this case series using a biologic mesh onlay.

Minimally invasive components separation--an updated method for closure of abdominal wall defects

PURPOSE

We describe a new minimally invasive percutaneous/laparoscopic-assisted technique based on the principles of the original open components separation described by Ramirez et al.

METHODS

The technique of minimally invasive components separation (MICS) is described in detail as a stepwise approach. The main advantages of MICS are compared with its traditional open counterpart and previously described endoscopic/laparoscopic modifications.

RESULTS

Open components separation is associated with increased wound problems due to extensive dissection. The MICS technique minimizes the need for large myocutaneous flap dissection, which in turn decreases postoperative wound complications. We have successfully corrected abdominal defects as large as 12 cm in diameter (113 cm(2)) with our MICS technique in a high-risk group of patients with minimal morbidity.

CONCLUSION

The objectives of abdominal wall reconstruction, which includes restoring structural support, providing stable soft-tissue coverage, and optimizing aesthetic appearance, were all obtained with this newly described MICS technique. We believe that MICS is a safe, practical choice for repair of ventral hernia defects, because it minimizes postoperative morbidity and restores abdominal wall physiology.

Preliminary experience and development of an algorithm for the optimal use of the laparoscopic component separation technique for myofascial advancement during ventral incisional hernia repair

BACKGROUND

Component separation technique (CST) enables rectus abdominus medialization, but may cause wound complications. Few published outcomes exist involving laparoscopic CST. Our aim was to examine feasibility and outcomes involving open and laparoscopic (lap) CST during ventral incisional hernia repair (VIHR) and present an algorithm for ventral herniorrhaphy.

STUDY DESIGN

Our design was a retrospective cohort study. Over 22 months, 28 patients underwent one of the following: (i) unilateral (U-) lap CST with open VIHR [n = 5], (ii) bilateral (B-) lap CST with open VIHR [n = 7], (iii) B-lap CST with lap VIHR [n = 8], or (iv) B-open CST with open VIHR [n = 8]. Indications for open VIHR included mesh removal, concomitant visceral procedure, wound revision, thin/ulcerated skin, abdominal wall tumor, frozen abdomen, and/or off-midline hernia. During open VIHR, CST was performed in the Ramirez fashion. Lap CST was performed before intraperitoneal access in lap VIHR and after retrorectus dissection in open VIHR. Patient surveillance consisted of clinical encounters and telephone interviews.

RESULTS

Groups were similar regarding age, body mass index, American Society of Anesthesiologists classification, hernia width, operative time, and hospital stay. Six of the 20 patients who underwent open VIHR developed wound complications, and two required early reoperation. Four of the six with concomitant visceral procedures had wound complications. No laparoscopic VIHR patients had a wound complication. Based on 11 months' follow-up, one open VIHR patient has concern for recurrence.

CONCLUSIONS

Laparoscopic CST is feasible during open and laparoscopic VIHR, but it appears most beneficial for wound healing after laparoscopic VIHR. During open VIHR, laparoscopic CST may not substantially reduce wound complications.

Which patients benefit most from laparoscopic ventral hernia repair? A comparative study

PURPOSE

To establish which patients suffering ventral hernia benefit the most from laparoscopic approach.

METHODS

From January 2005 to October 2008, 126 patients underwent surgery due to incisional hernia at our University Hospital. Patients were assigned to laparoscopic surgery (n=60) or conventional surgery (n=66) at the surgeon's discretion. Patients were subdivided according to the greater diameter of the defect: (G1, defect <5 cm; G2, defect 5 to 15 cm; and G3, defect >15 cm). Data on patient demographic, clinical, and perioperative variables were collected prospectively.

RESULTS

Groups were comparable in terms of sex, body mass index, American Society of Anesthesiologists score, size of defect, and proportion of primary repairs. Four patients were converted to open surgery. Mean hospital stay in the group with the smaller hernias (G1 was 3.16 d laparoscopic surgery vs. 2.87 d conventional surgery, P>0.05). Hospital stay for patients who underwent laparoscopy was shorter in G3 (4.25 d Lap vs. 12.6 d Open; P=0.02).

CONCLUSIONS

Patients with very large incisional hernias are those who benefit the most from laparoscopic treatment.

Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique

BACKGROUND

Most ventral incisional hernias are repaired using 1 of 2 principal techniques: (1) prosthetic repair (open or laparoscopic) and (2) primary reconstruction by fascial component separation. Primary midline restoration provides physiological advantages, and avoidance of mesh may reduce complications. This report describes 128 cases of incisional hernia repair by fascial release. Evolution of the technique produced modifications and fewer complications.

METHODS

Fascial component separation was performed either by "classic" technique (broad skin flaps) in group 1 and by "perforator preservation" (fascial release through separate inferolateral incisions) in group 2.

RESULTS

Mortality was .75% (1/128). Major complications occurred in 7 patients (5.5%). Total recurrence rate is 16% (21/128) with major recurrences in 9.3% (12/128). Both groups were statistically equivalent in demographics, comorbidities, and recurrences. Group 1 had significantly higher rates of skin necrosis (P < .001) and chronic pain (P = .003).

CONCLUSIONS

Fascial component separation can provide satisfactory results in uncomplicated incisional hernias, but skin necrosis is prohibitive without perforator preservation.

A case series of laparoscopic components separation and rectus medialization with laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair has been shown to offer improved patient recovery, when compared to open repair. It has also been shown to offer a lower complication rate. However, in patients with high body-mass index and large defects, the intraperitoneal on-lay technique of laparoscopic repair is criticized for an increased incidence of failure. In 1990, a study introduced the technique of open-component separation, hence enabling the medialization of the rectus muscle and decreasing the incidence of recurrence associated with primary repair. Open-component separation is associated with increased wound problems due to extensive dissection. Different laparoscopic and endoscopic modifications to the open-component-separation technique have been tried to minimize wound problems. In this article, we present our case series of 4 patients involving the laparoscopic component-separation technique of rectus medialization and, laparoscopic ventral hernia combined. This is one of the first series ever reported to involve both modalities of hernia repair in using an exclusive laparoscopic technique.

Early Results of Midline Hernia Repair Using a Minimally Invasive Component Separation Technique

A minimally invasive component separation may lead to a dynamic abdominal wall after hernia repair, with reduced complications. We present early results of our patients undergoing this technique. Five patients were selected for open midline repairs; three with chronic infections, one with a prior midline skin graft, and one who desired a primary, tension-free repair. These three males and two females had a mean age of 50.8 ± 21.1 years and body mass index of 30.9 ± 6.2. The mean number of previous abdominal operations was 7 ± 3.4 and previous attempted hernia repairs were 4 ± 2.7. All patients had a midline laparotomy with lysis of adhesions. An endoscopic component separation was then performed bilaterally. Drains were left in the dissection bed. All patients had the midline closed; four received biologic mesh underlays. Mean operative time was 227 minutes ± 49. Mean length of stay (LOS) was 9.2 days ± 3.6. Early median follow-up was 6 months (range 0.25–9). Two patients required postop transfusions, and two patients had mild complications of the midline wound (hematoma, infection). To date, one recurrence was diagnosed by CT scan. Early evaluation of adopting the minimally invasive (MIS) component separation demonstrates minimal complications and good initial outcomes.

Components Separation: A Solution to Complex Abdominal Wall Defects

Complex abdominal wall hernias can be challenging to treat. The purpose of this study was to retrospectively review the results of components separation. Seventeen patients underwent components separation between 2000 and 2007. Mean size of the hernia defect was 318 cm2. Mean number of prior abdominal operations/patient was 3.2. Nine patients (53%) had prior failed repair. At time of components separation, five patients (29%) had concurrent gastrointestinal operations and two (12%) had panniculectomy. Mean hospitalization stay was 3.8 days with a readmission rate of 41 per cent. The most common postoperative complications were wound related and occurred in 35 per cent of patients. During a mean follow-up of 21 months, only one patient had recurrent hernia (6%). Five patients (29%) required additional operations. Components separation is a viable option for patients with complex abdominal wall defects. Long-term recurrence is rare but wound related complications, operative reinterventions, and hospital readmission are common.

Mesh repair of common abdominal hernias: a review on experimental and clinical studies

Results on hernia surgery from numerous centers confirm that tensionless repair with various meshes reduces the complication rates and the frequency of recurrences. Some evidence on incisional hernias suggests, however, that the use of mesh seems to transfer the onset of recurrences by several years. Persistent pain and other discomfort is also an unpleasant complication of otherwise successful surgery in a number of patients. Thus, improved, slowly degrading, mesh materials, with strong connective tissue-inducing action, might be more optimal for hernia surgery. Accumulating evidence also suggests that recurrent hernias appear in patients having inherited weakness of connective tissues. Numerous tissue specific collagens, in addition to the classical fibrillar I-III collagens and numerous substrate specific matrix proteinases, have recently been described in biochemical literature, and their roles as possible causes of tissue weakness are discussed.

Medical effectiveness and safety of conventional compared to laparoscopic incisional hernia repair: a systematic review

BACKGROUND

Incisional hernias are a common complication following abdominal surgery and represent about 80% of all ventral hernia. In uncomplicated postoperative follow-up they develop in about 11% of cases and in up to 23% of cases with wound infections or other forms of wound complications. While conventional mesh repair has been the standard of care in the past, the use of laparoscopic surgery is increasing. It therefore remains uncertain which technique should be recommended as the standard of care.

OBJECTIVES

To compare the medical effectiveness and safety of conventional mesh and laparoscopic incisional hernia repair.

METHODS

A structured literature search of databases accessed through the German Institute of Medical Documentation and Information (DIMDI) was conducted. English and German literature published until August 2005 was included and their methodological quality assessed.

RESULTS

The search identified 17 relevant publications and included 15 studies for final assessment. Among those were one meta-analysis, one randomized clinical trial (RCT) ,and 13 cohort studies. All studies suffered from significant methodological limitations, such as differences in baseline characteristics between treatment groups, small case numbers, and the lack of adjustment for relevant confounders. Overall, medical effectiveness and safety were similar for both surgical approaches. However, there was a trend towards lower recurrence rates, length of hospital stay, and postoperative pain as well as decreased complication rates for the laparoscopic repair in the majority of studies. The impact of the technique of mesh implantation and mesh fixation as well as the impact of certain patient-related factors was not systematically assessed in any of the studies.

CONCLUSION

No conclusive differences could be identified between the operative techniques. There was, however, some evidence for a trend towards similar or slightly improved outcomes associated with the laparoscopic procedure. There remains an urgent need for high-quality prospective studies to evaluate this question conclusively.