Incisional hernia repair - laparoscopic or open surgery?

A comparative study in elective repair of large incisional hernias using on-lay mesh vs. sub-lay mesh: a meta-analysis

Ventral abdominal wall incisional hernia is defined as a defect in the musculo-fascial layers of the abdominal wall in the region of the postoperative scar. There is a slight increase in the incidence of incisional hernia in the female gender. The higher percentage of incisional hernia in females might be due to laxity of abdominal wall muscles after multiple pregnancies and also an increased incidence of obesity in females. To assess incisional hernia repair using two different techniques: on-lay mesh and sub-lay mesh, as regards operative time, postoperative recurrence, wound infection, seroma, hematoma, and flap necrosis. Pubmed, Web of Science, and Scopus were searched on 15 March 2022. The keywords incisional hernia, sub-lay mesh on-lay mesh, retromuscular mesh, and polypropylene. According to our results, there is a statistical difference between onlay and sublay regarding intra-operative time as sublay mesh is more time-consuming. Regarding postoperative complications, there is no statistical difference in recurrence, seroma, hematoma, flap necrosis, and infection but there is a statistical difference regarding in hospital stay as patients with sub-lay repair stays less than only.

Vermiform Appendix within Post-Laparoscopic Incisional Hernia: A Unique Case Report and Literature Review

Background: Appendicitis within incisional hernia is an extraordinarily rare postoperative complication with an incidence range from 0.08 to 1%. From the 14 cases that we found in the English literature, only three present appendixes vermiform in incisional hernia followed by laparoscopic surgery. Only two cases are treated minimally invasively by the laparoscopic approach. Case presentation: We introduce a 65-year-old man who had a laparoscopic sigmoid colon resection and had a lump found at the 12 mm trocar site in the right iliac area in the late postoperative phase. There were no complaints from the patient. A vermiform appendix was unexpectedly discovered in the sac of that incisional hernia during control CT scans performed by chemotherapists. Laparoscopic hernia repair without appendectomy was performed. Postoperative outcomes were excellent. Conclusions: Because of low incidence and a lack of distinctive clinical presentation of appendicitis within incisional hernia, there is a risk of delayed perioperative diagnosis and treatment. A CT scan might play an important role in verifying the diagnosis early. For better postoperative outcomes, if possible, laparoscopic surgery should be chosen.

Abdominal wall complications after kidney transplantation: A clinical review

Introduction

Abdominal wall complications are common after kidney transplantation, and although they have a minor impact on patient and graft survival, they increase the patient's morbidity and may have an impact on quality of life. Abdominal wall complications have an overall incidence of 7.7–21%.

Methods

This review will explore the natural history of abdominal wall complications in the kidney transplant setting, with a special focus on wound dehiscence and incisional herni, with a particular emphasis on risk factors, clinical characteristics, and treatment.

Results

Many patient‐related risk factors have been suggested, including older age, obesity, and smoking, but kidney transplant recipients have an additional risk related to the use of immunosuppression. Wound dehiscence usually does not require surgical intervention. However, for deep dehiscence involving the fascial layer with concomitant infection, surgical treatment and/or negative pressure wound therapy may be required.

Conclusions

Incisional hernia (IH) may affect 1.1–18% of kidney transplant recipients. Most patients require surgical treatment, either open or laparoscopic. Mesh repair is considered the gold standard for the treatment of IH, since it is associated with a low rate of postoperative complications and an acceptable rate of recurrence. Biologic mesh could be an attractive alternative in patients with graft exposition or infection.

Incisional Hernia Repairs after Abdominal Organ Transplantation

Incisional hernias occur after abdominal organ transplantation with rates of 1.6 per cent to 18 per cent in kidney transplants (KTs) and 1.7 to 32.4 per cent in liver transplants (LTs). We hypothesized a difference in KTand LToutcomes in patients with and without repair of incisional hernias. We conducted a retrospective cohort study of abdominal transplants from 2012 through 2016. The difference across compared groups for continuous variables was assessed using the independent sample t test, and for binary variables, using the chi-squared test. A total of 1518 transplants were performed, including 1138 KTs and 380 LTs. There were 83 KT incisional hernias (67 repaired) and 59 LT incisional hernias (48 repaired). There was no difference between groups with regard to smoking, diabetes, age, BMI, days on dialysis (KTs), pretransplant Model for End-Stage Liver Disease (MELD) (LTs), cold ischemic time, graft survival, or recurrence rate by repair method. In the LT population, there was a statistically significant difference in days on the waitlist ( P = 0.02), drain placement ( P = 0.04), and cytomegalovirus (CMV) mismatch ( P = 0.02). Patient survival was also statistically significant for KTs ( P = 0.04) and LTs ( P = 0.01). KT and LT patients who have their incisional hernias repaired have better overall survival, regardless of the repair technique.

Comparison of Mesh Fixation Techniques in Elective Laparoscopic Repair of Incisional Hernia-ReliaTack™ v ProTack™ (TACKoMesh) - A double-blind randomised controlled trial

Background

Minimally invasive incisional hernia repair has been established as a safe and efficient surgical option in most centres worldwide. Laparoscopic technique includes the placement of an intraperitoneal onlay mesh with fixation achieved using spiral tacks or sutures. An additional step is the closure of the fascial defect depending upon its size. Key outcomes in the evaluation of ventral abdominal hernia surgery include postoperative pain, the presence of infection, seroma formation and hernia recurrence. TACKoMESH is a randomised controlled trial that will provide important information on the laparoscopic repair of an incisional hernia; 1) with fascial closure, 2) with an IPOM mesh and 3) comparing the use of an articulating mesh-fixation device that deploys absorbable tacks with a straight-arm mesh-fixation device that deploys non-absorbable tacks.

Methods

A prospective, single-centre, double-blinded randomised trial, TACKoMESH, will establish whether the use of absorbable compared to non-absorbable tacks in adult patients undergoing elective incisional hernia repair produces a lower rate of pain both immediately and long-term. Eligible and consenting patients will be randomized to surgery with one of two tack-fixation devices and followed up for a minimum one year. Secondary outcomes to be explored include wound infection, seroma formation, hernia recurrence, length of postoperative hospital stay, reoperation rate, operation time, health related quality of life and time to return to normal daily activity.

Discussion

With ongoing debate around the best management of incisional hernia, continued trials that will add substance are both necessary and important. Laparoscopic techniques have become established in reducing hospital stay and rates of infection and report improvement in some patient centered outcomes whilst achieving similarly low rates of recurrence as open surgical techniques. The laparoscopic method with tack fixation has developed a reputation for its tendency to cause post-operative pain. Novel additions to technique, such as intraoperative-sutured closure of a fascial defect, and developments in surgical technology, such as the evolution of composite mesh design and mesh-fixation devices, have brought about new considerations for patient and surgeon. This study will evaluate the efficacy of several new technical considerations in the setting of elective laparoscopic incisional hernia repair.

Trial registration

Name of registry - ClinicalTrials.gov Registration number: NCT03434301. Retrospectively registered on 15th February 2018.

Continuous local analgesia is effective in postoperative pain treatment after medium and large incisional hernia repair

INTRODUCTION

Incisional hernias are a frequent complication of laparotomy. Open surgery is still an option for the treatment of incisional hernias with medium and large wall defects. Major opioids are routinely used in the treatment of postoperative pain, with several side effects. Continuous local analgesia can be effective in postoperative pain management after various surgical interventions. However, very few reports exist on its application in incisional hernias.

PURPOSE

We assessed the effectiveness of ropivacaine in reducing the need for systemic analgesics in postoperative pain management related to these interventions.

METHODS

We conducted an open-label, prospective, randomized design study. One hundred patients with medium and large incisional hernias were treated by open surgery. Thirty patients with abdominal defects > 8 cm received continuous postoperative local analgesia with ropivacaine 5 mg/ml. Thirty four and 36 patients (abdominal defects of more, and respectively less than 8 cm) received conventional analgesia.

RESULTS

Continuous local anesthesia during the first 72 h after surgery reduced the number of patients needing analgesia with pethidine (17 vs 47% and 53%, p = 0.006), as well as the cumulative doses of pethidine (p < 0.05), tramadol (p < 0.001), and metamizole (p < 0.001) needed to control postoperative pain. Catheter installation for local anesthesia did not increase surgery time (p = 0.16) or the rate of local complications.

CONCLUSION

Continuous local analgesia reduces the need for systemic opioids and can be successfully used in the postoperative pain management after medium and large incisional hernias treated by open surgery.

Procedural volume, cost, and reimbursement of outpatient incisional hernia repair: implications for payers and providers

OBJECTIVE

This analysis aimed to evaluate trends in volumes and costs of primary elective incisional ventral hernia repairs (IVHRs) and investigated potential cost implications of moving procedures from inpatient to outpatient settings.

METHODS

A time series study was conducted using the Premier Hospital Perspective^® Database (Premier database) for elective IVHR identified by International Classification of Diseases, Ninth revision, Clinical Modification codes. IVHR procedure volumes and costs were determined for inpatient, outpatient, minimally invasive surgery (MIS), and open procedures from January 2008-June 2015. Initial visit costs were inflation-adjusted to 2015 US dollars. Median costs were used to analyze variation by site of care and payer. Quantile regression on median costs was conducted in covariate-adjusted models. Cost impact of potential outpatient migration was estimated from a Medicare perspective.

RESULTS

During the study period, the trend for outpatient procedures in obese and non-obese populations increased. Inpatient and outpatient MIS procedures experienced a steady growth in adoption over their open counterparts. Overall median costs increased over time, and inpatient costs were often double outpatient costs. An economic model demonstrated that a 5% shift of inpatient procedures to outpatient MIS procedures can have a cost surplus of ∼ US $1.8 million for provider or a cost-saving impact of US $1.7 million from the Centers for Medicare & Medicaid Services perspective.

LIMITATIONS

The study was limited by information in the Premier database. No data were available for IVHR cases performed in free-standing ambulatory surgery centers or federal healthcare facilities.

CONCLUSION

Volumes and costs of outpatient IVHRs and MIS procedures increased from January 2008-June 2015. Median costs were significantly higher for inpatients than outpatients, and the difference was particularly evident for obese patients. A substantial cost difference between inpatient and outpatient MIS cases indicated a financial benefit for shifting from inpatient to outpatient MIS.

Association Between Delayed Graft Function and Incisional Hernia after Renal Transplant

OBJECTIVES

Incisional hernias can occur after any abdominal operation, including after renal transplant. Several risk factors have been identified in nonimmunosuppressed surgical patients. We aimed to identify whether specific risk factors correlated with the development of incisional hernias after renal transplant. The existence of associations between these risk factors and postoperative complications was also reviewed.

MATERIALS AND METHODS

We reviewed 969 kidney transplants performed between February 2000 and January 2011. Thirty-nine kidney transplant recipients who were treated with rapamycin were excluded. The following potential risk factors were evaluated: recipient age, sex, body mass index at transplant, delayed graft function, diabetes, albumin, postoperative platelet count, drain placement, donor body mass index, donor type, warm ischemic time, and cold ischemic time. We performed univariate and multivariate logistic regression tests.

RESULTS

In our patient group, a total of 52 (5.4%) transplants were complicated by incisional hernia. On univariate analysis, we found that delayed graft function (P = .001) and infection (P < .001) were statistically significant predictors for development of incisional hernia. Multivariate analyses revealed that delayed graft function and length of stay remained statistically significant predictors.

CONCLUSIONS

Delayed graft function and length of stay are significant predictors of incisional hernia after kidney transplant.

Trans-fascial laparoscopic mesh fixation: a procedural comparison using the standard suture passer versus iMESH stitcher™ device

INTRODUCTION

Laparoscopic mesh repair has become an increasingly common method for repairing incisional hernias. The current method for fixating mesh to the abdominal wall includes tacking the mesh to the peritoneum and fascia and suturing the mesh to the fascia with trans-fascial sutures. The iMESH Stitcher™ is a stitching device developed to both simplify and expedite this procedure by passing the suture from one arm of the iMESH stitcher™ to the other. The device enables a stitch to be created in three quick moves using only one hand. We compared both the efficacy and procedure time of trans-fascial mesh fixation when performed with the iMESH stitcher™ as compared to the standard suture passer method.

METHODS

A mesh patch was installed on the internal abdominal wall of two pigs. Surgical residents and Medical students were participants in the study and were trained in both techniques. Each participant was asked to perform six fixations with each technique. The procedural time required for both fixation techniques was recorded. Participants were asked to assess subjectively the relative difficulty of each technique on a scale of 1-10 (10 = most difficult).

RESULTS

Sixteen residents and students performed a total of 12 mesh fixations, each performing 6 fixations with each technique. Average mesh fixation suture time using the suture passer technique was 44 s for residents and 47 s for students. Average fixation suture time using the iMESH stitcherTM was 17 s for residents and 15 s for students. The average difficulty score for the suture passer technique was 6.1 as compared to 2.9 with iMESH stitcher™.

CONCLUSION

Trans-fascial fixation with the iMESH Stitcher™ took significantly less time than the standard suture passer method. The iMESH Stitcher™ significantly simplifies the procedure of transfascial fixation and potentially reduces technical difficulties.