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Hope WW. State of the Art: Advances in Hernia Care. Am Surg 2024; 90:1983-1989. [PMID: 38527961 DOI: 10.1177/00031348241241717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The field of hernia surgery has seen many recent advances and continues to evolve. Care of the hernia patient begins preoperatively by ensuring adequate preparation for surgery with surgeons now having the opportunity to accurately predict risk which can aid with informed consent. Imaging studies can now help surgeons diagnose and plan hernia surgery on an individual level based on hernia characteristics as well as abdominal wall musculature. In the operating room, new technology and surgical techniques have allowed surgeons to become increasingly sophisticated with goals of reducing tension on midline closures, utilizing minimally invasive and robotic techniques, and availability of new and varied mesh prosthetics. While modest improvements in outcomes have been witnessed by these advances, there is still opportunity for improvement which will be realized by continued research, use of registries, and education and training. Hernia prevention strategies focusing on minimally invasive surgery, laparotomy closure, and the use of prophylactic mesh will also help with the burden of incisional hernias. These advances in hernia surgery have led to the new field of Abdominal Core Health which helps represent this evolving and growing new subspecialty of general surgery.
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Affiliation(s)
- William W Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC
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Woo SH, Lee SJ, Park JY, Kim EK. The effect of preoperative botulinum toxin a injection on traction force during hernia repair: a prospective, single-blind study, intra-patient comparison using contralateral side as a control. Hernia 2024:10.1007/s10029-024-03087-9. [PMID: 38869813 DOI: 10.1007/s10029-024-03087-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE Ventral hernias are a common complication of laparotomy, posing challenges particularly when primary fascial closure is unattainable. Although chemical component separation using preoperative botulinum toxin A (BTX) injections has emerged as a promising adjunct, objective evidence of its efficacy remains limited. This study aimed to objectively assess the effect of preoperative BTX on traction force during ventral hernia repair. METHODS A prospective, single-blind study was conducted on patients with midline incisional hernias following liver transplantation. BTX was administered unilaterally, and the traction force required to medially advance the anterior rectus sheath was measured intraoperatively. Pre- and post-injection CT scans were analyzed for changes in hernia size and LAW muscle measurements. Statistical analyses were performed to evaluate traction force differences between BTX-injected and uninjected sides. RESULTS Ten patients underwent hernia repair with primary fascial closure achieved in all cases. Comparison of pre- and post-injection CT scans showed no significant changes in hernia size. LAW muscle length increased by 1.8 cm, while thickness decreased by 0.2 cm. Intraoperative traction force measurements revealed a significant reduction on the BTX-injected side compared to the uninjected side (p < 0.0001). The traction force ratio on the BTX-injected to the uninjected side averaged 57%, indicating the efficacy of BTX in reducing tension. CONCLUSION Preoperative BTX significantly reduces traction force during ventral hernia repair, highlighting its potential as an adjunctive therapy in complex cases. While challenges remain in patient selection and outcome assessment, BTX offers a promising avenue for enhancing abdominal wall reconstruction outcomes and reducing surgical complications.
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Affiliation(s)
- Soo Hyun Woo
- Department of Plastic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seok Joon Lee
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43gil, Songpa-gu, Seoul, 05505, Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43gil, Songpa-gu, Seoul, 05505, Korea.
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Peñafiel JAR, Valladares G, Cyntia Lima Fonseca Rodrigues A, Avelino P, Amorim L, Teixeira L, Brandao G, Rosa F. Robotic-assisted versus laparoscopic incisional hernia repair: a systematic review and meta-analysis. Hernia 2024; 28:321-332. [PMID: 37725188 DOI: 10.1007/s10029-023-02881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE This study aimed to perform a systematic review and meta-analysis comparing the efficacy and safety outcomes of robotic-assisted and laparoscopic techniques for incisional hernia repair. METHODS PubMed, Embase, Scopus, Cochrane databases, and conference abstracts were systematically searched for studies that directly compared robot-assisted versus laparoscopy for incisional hernia repair and reported safety or efficacy outcomes in a follow-up of ≥ 1 month. The primary endpoints of interest were postoperative complications and the length of hospital stay. RESULTS The search strategy yielded 2104 results, of which four studies met the inclusion criteria. The studies included 1293 patients with incisional hernia repairs, 440 (34%) of whom underwent robot-assisted repair. Study follow-up ranged from 1 to 24 months. There was no significant difference between groups in the incidence of postoperative complications (OR 0.65; 95% CI 0.35-1.21; p = 0.17). The recurrence rate of incisional hernias (OR 0.34; 95% CI 0.05-2.29; p = 0.27) was also similar between robotic and laparoscopic surgeries. Hospital length of stay (MD - 1.05 days; 95% CI - 2.06, - 0.04; p = 0.04) was significantly reduced in the robotic-assisted repair. However, the robot-assisted repair had a significantly longer operative time (MD 69.6 min; 95% CI 59.0-80.1; p < 0.001). CONCLUSION The robotic approach for incisional hernia repair was associated with a significant difference between the two groups in complications and recurrence rates, a longer operative time than laparoscopic repair, but with a shorter length of stay.
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Affiliation(s)
- J A R Peñafiel
- Department of Surgery, University of Cuenca, Cuenca, Ecuador
- Health Sciences Faculty, Universidad Internacional, Quito, Ecuador
| | - G Valladares
- Department of Mathematics, University Central of Ecuador, Quito, Ecuador.
- Francisco Viteri and Gato Sobral, Universidad Central of Ecuador, Campus Universitario, Pichincha, Ecuador.
| | - Amanda Cyntia Lima Fonseca Rodrigues
- Department of Medicine, Positivo University, Curitiba, Brazil
- Department of Statistics and Biostatistics, Anhembi Morumbi University, Curitiba, Brazil
| | - P Avelino
- Department of Surgery, Federal University of Rio Grande do Norte, Natal, Brazil
| | - L Amorim
- Department of Surgery, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - L Teixeira
- Department of Surgery, University of UniEvangelica, Anapolis, Brazil
| | - G Brandao
- Department of Surgery, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - F Rosa
- Department of Surgery, Instituto Tocantinense Presidente Antônio Carlos, Palmas, Tocantins, Brazil
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Lorenz WR, Holland AM, Augenstein VA. Will Quantifying Fascial Tension Change the Practice of Component Separations in Complex Abdominal Wall Reconstruction? JAMA Surg 2023; 158:1326-1327. [PMID: 37792329 DOI: 10.1001/jamasurg.2023.4853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Affiliation(s)
- William R Lorenz
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Alexis M Holland
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
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Miller BT, Ellis RC, Petro CC, Krpata DM, Prabhu AS, Beffa LRA, Huang LC, Tu C, Rosen MJ. Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release. JAMA Surg 2023; 158:1321-1326. [PMID: 37792324 PMCID: PMC10551814 DOI: 10.1001/jamasurg.2023.4847] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/16/2023] [Indexed: 10/05/2023]
Abstract
Importance Posterior components separation (PCS) is a commonly used myofascial release technique in ventral hernia repairs. The contribution of each release with anterior and posterior fascial advancement has not yet been characterized in patients with ventral hernias. Objective To quantitatively assess the changes in tension on the anterior and posterior fascial elements of the abdominal wall during PCS to inform surgeons regarding the technical contribution of each step with those changes, which may help to guide intraoperative decision-making. Design, Setting, and Participants This case series enrolled patients from December 2, 2021, to August 2, 2022, and was conducted at the Cleveland Clinic Center for Abdominal Core Health. The participants included adult patients with European Hernia Society classification M1 to M5 ventral hernias undergoing abdominal wall reconstruction with PCS. Intervention A proprietary, sterilizable tensiometer measured the force needed to bring the fascial edge of the abdominal wall to the midline after each step of a PCS (retrorectus dissection, division of the posterior lamella of the internal oblique aponeurosis, and transversus abdominis muscle release [TAR]). Main Outcome The primary study outcome was the percentage change in tension on the anterior and posterior fascia associated with each step of PCS with TAR. Results The study included 100 patients (median [IQR] age, 60 [54-68] years; 52 [52%] male). The median (IQR) hernia width was 13.0 (10.0-15.2) cm. After complete PCS, the mean (SD) percentage changes in tension on the anterior and posterior fascia were -53.27% (0.53%) and -98.47% (0.08%), respectively. Of the total change in anterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -82.56% (0.68%), incision of the posterior lamella of the internal oblique with a change of -17.67% (0.41%), and TAR with no change. Of the total change in posterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of -3.04% (2.42%), incision of the posterior lamella of the internal oblique with a change of -58.78% (0.39%), and TAR with a change of -38.17% (0.39%). Conclusions and Relevance In this case series, retrorectus dissection but not TAR was associated with reduced tension on the anterior fascia, suggesting that it should be performed if anterior fascial advancement is needed. Dividing the posterior lamella of the internal oblique aponeurosis and TAR was associated with reduced tension on the posterior fascia, suggesting that it should be performed for posterior fascial advancement.
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Affiliation(s)
- Benjamin T. Miller
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ryan C. Ellis
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C. Petro
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajita S. Prabhu
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lucas R. A. Beffa
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J. Rosen
- Department of Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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CT-measured hernia parameters can predict component separation: a cross-sectional study from China. Hernia 2023:10.1007/s10029-023-02761-8. [PMID: 36934216 DOI: 10.1007/s10029-023-02761-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/12/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE Currently, there are no reliable preoperative methods for predicting component separation (CS) during incisional hernia repair. By quantitatively measuring preoperative computed tomography (CT) imaging, we aimed to assess the value of hernia defect size, abdominal wall muscle quality, and hernia volume in predicting CS. METHODS The data of 102 patients who underwent open Rives-Stoppa retro-muscular mesh repair for midline incisional hernia between January 2019 and March 2022 were retrospectively analyzed. The patients were divided into two groups: ''CS group'' patients who required CS to attempt fascial closure, and ''non-CS'' group patients who required only Rives-Stoppa retro-muscular release to achieve fascial closure. Hernia defect width, hernia defect angle, rectus width, abdominal wall muscle area and CT attenuation, hernia volume (HV), and abdominal cavity volume (ACV) were measured on CT images. The rectus width to defect width ratio (RDR), HV/ACV, and HV/peritoneal volume (PV; i.e., HV + ACV) were calculated. Differences between the indices of the two groups were compared. Logistic regression models were applied to analyze the relationships between the above CT parameters and CS. Receiver operator characteristic (ROC) curves were generated to evaluate the potential utility of CT parameters in predicting CS. RESULTS Of the102 patients, 69 were in the non-CS group and 33 were in the CS group. Compared with the non-CS group, hernia defect width (P < 0.001), hernia defect angle (P < 0.001), and hernia volume (P < 0.001) were larger in the CS group, while RDR (P < 0.001) was smaller. The abdominal wall muscle area in the CS group was slightly greater than that in the non-CS group (P = 0.046), and there was no significant difference in the CT attenuation of the abdominal wall muscle between the two groups (P = 0.089). Multivariate logistic regression identified hernia defect width (OR 1.815, 95% CI 1.428-2.308, P < 0.001), RDR (OR 0.018, 95% CI 0.003-0.106, P < 0.001), hernia defect angle (OR 1.077, 95% CI 1.042-1.114, P < 0.001), hernia volume (OR 1.002, 95% CI 1.001-1.003, P < 0.001), and CT attenuation of abdominal wall muscle (OR 0.962, 95% CI 0.927-0.998, P = 0.037) as independent predictors of CS. Hernia defect width was the best predictor for CS, with a cut-off point of 9.2 cm and an area under the curve (AUC) of 0.890. The AUCs of RDR, hernia defect angle, hernia volume, and abdominal wall muscle CT attenuation were 0.843, 0.812, 0.747, and 0.572, respectively. CONCLUSION Quantitative CT measurements are of great value for preoperative prediction of CS. Hernia defect size, hernia volume, and the CT attenuation of abdominal wall muscle are all preoperative predictive indicators of CS.
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Is There Indication for the Use of Biological Mesh in Cancer Patients? J Clin Med 2022; 11:jcm11206035. [PMID: 36294356 PMCID: PMC9605183 DOI: 10.3390/jcm11206035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 12/01/2022] Open
Abstract
Up to 28% of all patients who undergo open surgery will develop a ventral hernia (VH) in the post-operative period. VH surgery is a debated topic in the literature, especially in oncological patients due to complex management. We searched in the surgical database of the Hepatobiliary Unit of the National Cancer Institute of Naples “G. Pascale Foundation” for all patients who underwent abdominal surgery for malignancy from January 2010 to December 2018. Our surgical approach and our choice of mesh for VH repair was planned case-by-case. We selected 57 patients that fulfilled our inclusion criteria, and we divided them into two groups: biological versus synthetic prosthesis. Anterior component separation was used in 31 patients (54.4%) vs. bridging procedure in 26 (45.6%). In 41 cases (71.9%), we used a biological mesh while a synthetic one was adopted in the remaining patients. Of our patients, 57% were male (33 male vs. 24 female) with a median age of 65 and a mean BMI of 30.8. We collected ventral hernia defects from 35 cm2 to 600 cm2 (mean 205.2 cm2); 30-day complications were present in 24 patients (42.1%), no 30-day mortality was reported, and 21 patients had a recurrence of pathology during study follow-up. This study confirms VH recurrence risk is not related with the type of mesh but is strongly related with BMI and type of surgery also in oncological patients.
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Faustino LD, Ferreira LM, Ramirez OM, Nahas FX. Components separation technique of the abdominal wall: Which muscle release produces the greatest reduction in tension on the mideline? J Plast Reconstr Aesthet Surg 2021; 74:3361-3370. [PMID: 34229956 DOI: 10.1016/j.bjps.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/24/2021] [Accepted: 05/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The components separation technique (CS) is used for the reconstruction of complex abdominal wall defects. Release and undermining of the rectus abdominis muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline, reducing recurrence of ventral hernia, but causes major changes in the physiology of abdominal wall. The purpose of the study was to determine which muscle release and undermining produces the lowest tension on the midline. METHODS Twenty fresh cadavers were dissected and the anterior and posterior layers of the rectus sheath were isolated in the midline. The forces necessary to advance the layers of the rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after release and undermining of the right RAM and left EOM; and after release and undermining of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for the different muscles involved, layers of the rectus sheath, measurement points, and stages of separation. RESULTS Tension on the abdominal midline after the release and undermining of both the RAM and EOM was reduced by 56% (p <0.05), 42% after the release and undermining of the EOM alone (p <0.05), and 35% after release and undermining of the RAM alone (p <0.05). CONCLUSION Release and undermining of the EOM by CS led to lower tension on the abdominal midline compared to that associated with the release of the RAM alone.
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Affiliation(s)
- Leandro Dario Faustino
- Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Lydia Masako Ferreira
- Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Oscar M Ramirez
- Division of Plastic Surgery, Cleveland Clinic, Fort Lauderdale, FL, United States
| | - Fábio Xerfan Nahas
- Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
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