The Use of Inlay Bridge of the Posterior Fascia as Adjuvants to a Modified Rives-Stoppa Repair for Difficult Abdominal Wall Hernias

BACKGROUND

Major abdominal wall defects remain a highly morbid complication. Occasionally a fascial defect is encountered, that despite all surgical efforts, is unable to completely approximate at the midline. Here we describe our method and outcomes of using a bridging mesh when the posterior fascia was unable to be approximated during the repair of large postoperative ventral hernias using the modified Rives-Stoppa technique.

METHODS

A retrospective review was conducted looking at all the open abdominal wall hernia repairs between 2014 and 2020. The cohort of patients who had a bridge placed in addition to the traditional open modified Rives-Stoppa repair were used for this study.

RESULTS

Nineteen patients had a mesh inlay bridge placed in addition to a modified Rives-Stoppa repair with a sublay (retrorectus) Ultrapro mesh. For the inlay mesh 13 Symbotex composite meshes were placed and 6 Vicryl meshes used. The average surface area of the defect was 358.1 cm^2. The average length of hospitalization was 8.8 days with a range of 3-24 days. During the immediate postoperative course there were 6 minor complications. During the follow-up period there were 2 recurrences.

DISCUSSION

The use of inlay mesh bridge as an adjuvant to a modified Rives-Stoppa repair with a sublay ultrapro mesh is an effective technique for difficult abdominal wall repairs where the posterior fascia is unable to be approximated without tension.

Defining Wider Indications for Stoppa Repair Other Than Recurrent Hernias

Managing complex inguinal hernias has been a constant challenge for surgeons and its treatment is not without challenges with the routine current techniques. Complex inguinal hernias especially recurrent have been managed by the Rives-Stoppa technique which is an established suture-less, tension-free, and absolute method of treatment with minimal recurrence rates. Traditionally, this surgical technique is most indicated in recurrent inguinal hernias, but we aim to assess the usefulness of this procedure for the treatment of complex inguinal hernias in individuals presenting for the first time. We report four varied cases of complex inguinal hernias, repaired by the open Rives-Stoppa technique, and discuss its indications, technique of repair, and current status.

Favourable outcomes after Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Non-Complex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-Analysis

OBJECTIVE

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

SUMMARY BACKGROUND DATA

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For non-complex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

METHODS

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

RESULTS

Ninety-three studies representing 12440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% (95%CI: 2.2-4.2%, n = 11049) after minimally 12 months and 4.1%, (95%CI: 2.9-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2-6.4%, n = 4891) and 5.5% (95%CI: 4.4-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (OR: 0.27, 95%CI: 0.15-0.51, p < 0.001) and equal recurrence rates compared to intraperitoneal onlay (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03-3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8-2.8%, n = 982), albeit based on non-randomized studies.

CONCLUSIONS

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except surgical site infection. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

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.

Prophylactic negative pressure wound therapy after open ventral hernia repair: a systematic review and meta-analysis

PURPOSE

Negative pressure wound therapy on closed incisions (iNPWT) is a wound dressing system developed to promote wound healing and avoid complications after surgical procedures. The effect of iNPWT is well established in various surgical fields, however, the effect on postoperative wound complications after ventral hernia repair remains unknown. The aim of this systematic review and meta-analysis was to investigate the effect of iNPWT on patients undergoing open ventral hernia repair (VHR) compared with conventional wound dressing.

MATERIALS AND METHODS

This systematic review and meta-analysis followed the PRISMA guidelines. The databases PubMed, Embase, Cochrane Library, Web of science and Cinahl were searched for original studies comparing iNPWT to conventional wound dressing in patients undergoing VHR. The primary outcome was surgical site occurrence (SSO), secondary outcomes included surgical site infection (SSI) and hernia recurrence.

RESULTS

The literature search identified 373 studies of which 10 were included in the meta-analysis including a total of 1087 patients. Eight studies were retrospective cohort studies, one was a cross-sectional pilot study, and one was a randomized controlled trial. The meta-analysis demonstrated that iNPWT was associated with a decreased risk of SSO (OR 0.27 [0.19, 0.38]; P < 0.001) and SSI (OR 0.32 [0.17, 0.55]; P < 0.001). There was no statistically significant association with the risk of hernia recurrence (OR 0.62 [0.27, 1.43]; P = 0.26).

CONCLUSION

Based on the findings of this systematic review and meta-analysis iNPWT following VHR was found to significantly reduce the incidence of SSO and SSI, compared with standard wound dressing. INPWT should be considered for patients undergoing VHR.

Outcomes of biosynthetic absorbable mesh use in high risk CDC Class I ventral hernia repair: a single surgeon series

PURPOSE

Biosynthetic absorbable meshes have emerged as suitable alternatives to permanent synthetic and biologic meshes in complex ventral hernia repair in contaminated wounds. Evidence regarding the use of these products in clean wounds is currently scant. This paper presents a large single surgeon series using GORE^®BIO-A^® (W.L. Gore & Associates, Newark, DE) (Bio-A) tissue reinforcement in high risk patients with predominantly CDC Class I wounds.

METHODS

Retrospective review of a prospectively maintained database of consecutive patients who underwent open ventral hernia repair with biosynthetic absorbable mesh was conducted. Ventral Hernia Working Group (VHWG) classification based on patient demographics and Centers for Disease Control (CDC) wound type were collected prospectively. All patients were followed up for a minimum of 12 months post-operatively.

RESULTS

155 patients were included with a mean post-operative follow up of 29 months (range 12-62 months). Mean age was 61.8 years with an average BMI of 33.5 kg/m². 147 patients (94.9%) were classified as VHWG 2 or 3 based on comorbidities or surgical field contamination. 69% (n = 107) of wounds were designated CDC Class I. Mean hernia size was 119.7cm² with recurrent defects comprising 32.3% (n = 50). Retrorectus mesh repair was achieved in 84.5% of patients (n  = 131). Post-operative wound events occurred in 19.3%. No mesh was explanted. Hernia recurrence rate was 9.0% with a mean time to recurrence of 14 months. There was no significant difference in recurrence rates between clean and contaminated wounds.

CONCLUSION

This study supports the use of Bio-A in high risk ventral hernias, demonstrating a safe and durable repair across all wound classes. Ongoing follow-up continues to monitor for late complications and recurrence.

Endoscopic transposition with the hernial sac (eTHS) in ventral hernia repair - technical description

Incisional hernia is a late complication of the most frequent after abdominal surgeries, with resulting morbidity that can worsen the condition. The treatment has been done both by open techniques, using screens or not, and by laparoscopic and robotic methods, which use them systematically. However, introducing a permanent foreign body into the tissues requires more surgical time, despite not closing the parietal defect in most cases and a higher risk of infections. New technologies have been trying to improve these results, with absorbable prostheses (biological or synthetic), but their high cost and recurrences remain a severe problem. Even so, standard repair establishes reinforcement with screens, routine, and whether the approach is traditional or mini-invasive. The authors report their first case of endoscopic repair of incisional hernia, which occurred two years ago, with a Brazilian technique already fifty years old: the transposition with the hernia sac proposed by Prof. Alcino Lázaro da Silva in 1971.

Systematic Review of Tissue Expansion: Utilization in Non-breast Applications

Background

Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances.

Methods

The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed.

Results

A total of 565 publications were identified. Of these, 166 publications described tissue expansion for "less traditional" indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction.

Conclusions

Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

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.

Short-term safety of preoperative administration of botulinum toxin A for the treatment of large ventral hernia with loss of domain

PURPOSE

Preoperative intramuscular-administered botulinum toxin A (BTA) in the lateral abdominal muscles prior to abdominal wall reconstruction has been reported to produce a flaccid paralysis and improve the primary closure rate of large ventral hernias with loss of domain. Complications to this treatment remain sparsely described. The aim of the current study was to report safety and short-term outcome of abdominal wall reconstruction aided by BTA administration.

METHODS

This was a retrospective two-center study including all patients undergoing abdominal wall reconstruction for ventral hernia aided by preoperative BTA administration to the lateral abdominal muscles. Data were retrieved from patient charts and included preoperative demographic and perioperative information as well as postoperative 30-day complications and readmissions.

RESULTS

A total of 37 patients underwent BTA administration prior to hernia repair. The mean age and body mass index were 59.5 (SD 10.1) years and 31.1 (SD 5.2) kg/m². The BTA injections were administered mean 31.6 days (SD 10.0) prior to the hernia repair. One (2.7%) patient reported pain as a complication immediately after the BTA administration. Subsequent to the hernia repair, six (16.2%) patients were readmitted within 30 days. Nine patients (24.3%) had wound complications and medical complications occurred in seven (18.9%) patients.

CONCLUSIONS

We found early preoperative administration of BTA a safe adjunct to large ventral hernia repair, without adverse events related to the administration preoperative. Future studies should further highlight the efficacy of preoperative BTA for reconstruction of otherwise untreatable hernias.