Incisional hernia formation in hepatobiliary surgery using transverse and hybrid incisions: a systematic review and meta-analysis

Minimizing Incision in Living Donor Liver Transplantation: Initial Experience and Comparative Analysis of Upper Midline Incision in 115 Recipients

Living donor liver transplantation (LDLT) needs "Mercedes Benz" or "J-shaped" incision, causing short and long-term complications. An upper midline incision (UMI) is less invasive alternative but technically challenging. Reporting UMI for recipients in LDLT vs. conventional J-shaped incision. Retrospective analysis, July 2021 to December 2022. Peri-operative details and post-transplant outcomes of 115 consecutive adult LDLT recipients transplanted with UMI compared with 140 recipients with J-shaped incision. Cohorts had similar preoperative and intraoperative variables. The UMI group had significant shorter time to ambulation (3 ± 1.6 vs. 3.6 ± 1.3 days, p = 0.001), ICU stay (3.8 ± 1.3 vs. 4.4 ± 1.5 days, p = 0.001), but a similar hospital stay (15.6±7.6 vs. 16.1±10.9 days, p = 0.677), lower incidence of pleural effusion (11.3% vs. 27.1% p = 0.002), and post-operative ileus (1.7% vs. 9.3% p = 0.011). The rates of graft dysfunction (4.3% vs. 8.5% p = 0.412), biliary complications (6.1% vs. 12.1% p = 0.099), 90-day mortality (7.8% vs. 12.1% p = 0.598) were similar. UMI-LDLT afforded benefits such as reduced pleuropulmonary complications, better early post-operative recovery and reduction in scar-related complaints in the medium-term. This is a safe, non-inferior and reproducible technique for LDLT.

Incisional hernia repair following pancreatic surgery-open vs laparoscopic approach

INTRODUCTION

For pancreatic procedures, transverse and midline or combined approaches are used. Having an increased morbidity after pancreatic surgery, these patients have an increased risk of developing an incisional hernia. In the following, we will analyze how the results of incisional hernia surgery after pancreatic surgery are presented in the Herniamed Registry.

METHODS

Hospitals and surgeons from Germany, Austria and Switzerland can voluntarily enter all routinely performed hernia operations prospectively into the Herniamed Registry. All patients sign a special informed consent declaration that they agree to the documentation of their treatment in the Herniamed Registry. Perioperative complications (intraoperative complications, postoperative complications, complication-related reoperations and general complications) are recorded up to 30 days after surgery. After 1, 5, and 10 years, patients and primary care physicians are contacted and asked about any pain at rest, pain on exertion, chronic pain requiring treatment or recurrence. This retrospective analysis of prospectively collected data compares the outcomes of minimally invasive vs open techniques in incisional hernia repair after pancreatic surgery.

RESULTS

Relative to the total number of all incisional hernia patients in the Herniamed Registry, the proportion after pancreatic surgery with 1-year follow-up was 0.64% (n = 461) patients. 95% of previous pancreatic surgeries were open. Minimally invasive incisional hernia repair was performed in 17.1% and open repair in 82.9% of cases. 23.2% of the defects were larger than 10 cm and 32.8% were located laterally or were a combination of lateral and medial defects. Among the few differences between the collectives, a significantly higher rate of defect closure (58.1% vs 25.3%; p < 0.001) and drainage (72.8% vs 13.9%; p < 0.001) was found in the open repairs, and larger meshes were seen in the minimally invasive procedures (340.6 cm2 vs 259.6 cm2; p < 0.001). No difference deemed a risk factor for chronic postoperative pain was seen in the rate of preoperative pain between the open and minimally invasive procedures (Appendix Table 4) No significant differences were found in either the perioperative complications or at 1-year follow-up.

CONCLUSIONS

Incisional hernias after complex pancreatic surgery can be repaired safely and with a low recurrence rate in both open and minimally invasive techniques.

Comparison of open anterior component and open transversus abdominus release in repair of large subcostal hernias

BACKGROUND

Large subcostal incisional hernias are considered as complex defects, and a few different approaches have been described for repair. The purpose of this comparative cross-sectional study is to evaluate the outcomes of patients with large subcostal incisional hernias treated with either the open anterior components separation technique (ACS) or with the open transversus abdominis release technique (TAR).

METHODS

From the database of patients with large complex incisional hernias who underwent abdominal wall reconstruction with open techniques between April 2007 and October 2022 at our institution, on May 25th, 2023 we identified those whose hernias were located in the subcostal areas and who underwent reconstruction with a components separation technique and mesh. Perioperative variables and outcomes were compared between the patients with large subcostal hernias who underwent abdominal wall reconstruction with either the ACS or the TAR techniques.

RESULTS

Thirty-one patients with large subcostal hernias were included in the study. ACS and intra-abdominal mesh was used in 11 patients; TAR and retro-muscular mesh was performed in 20 patients. More postoperative local abdominal wall complications were seen in patients who had ACS as opposed to TAR (55% vs 15%, p = 0.02). Hernia recurrence was more common in patients who had ACS as opposed to TAR (55% vs 5%, p = 0.008).

CONCLUSIONS

More post-operative complications and recurrences were seen in patients who had ACS as opposed to TAR.

Incisional Hernia Following Open Pancreaticoduodenectomy: Incidence and Risk Factors at a Tertiary Care Centre

(1) Background: Incisional hernia (IH) is one of the most common complications following open abdominal surgery. There is scarce evidence on its real incidence following pancreatic surgery. The purpose of this study is to evaluate the incidence and the risk factors associated with IH development in patients undergoing pancreaticoduodenectomy (PD). (2) Methods: We retrospectively reviewed all patients undergoing PD between 2014 and 2020 at our centre. Data were extracted from a prospectively held database, including perioperative and long-term factors. We performed univariate and multivariate analysis to detect those factors potentially associated with IH development. (3) Results: The incidence of IH was 8.8% (19/213 patients). Median age was 67 (33-85) years. BMI was 24.9 (14-41) and 184 patients (86.4%) underwent PD for malignant disease. Median follow-up was 23 (6-111) months. Median time to IH development was 31 (13-89) months. Six (31.5%) patients required surgical repair. Following univariate and multivariate analysis, preoperative hypoalbuminemia (OR 3.4, 95% CI 1.24-9.16, p = 0.01) and BMI ≥ 30 kg/m2 (OR 2.6, 95% CI 1.06-8.14, p = 0.049) were the only factors independently associated with the development of IH. (4) Conclusions: The incidence of IH following PD was 8.8% in a tertiary care center. Preoperative hypoalbuminemia and obesity are independently associated with IH occurrence following PD.

Low incisional hernia incidence using a large-bite, low-tension technique for celiotomy closure

Background

Incisional herniae (IH) are reported in 5->20 % of patients undergoing open celiotomy, and can be linked to closure technique. The STITCH randomized trial favors a small bite technique for midline celiotomy closure with a 1-year IH rate of 13 % over larger bites (23 %).

Methods

A continuous musculofascial mass closure with absorbable looped #1 PDS suture with 2-cm bite size was used for all open celiotomies. IH frequency and associated clinicopathologic factors were retrospectively analyzed from prospective data in 336 consecutive patients undergoing visceral resections by a single surgeon.

Results

The study population included 192 men and 144 women, 81 % of whom had a cancer diagnosis, who underwent hepatobiliary, pancreatic, gastroesophageal, and colorectal resections, or a combination. The majority of patients (84 %) had subcostal incisions, and 10 % received a midline incision. At a median follow-up of 19.5 months, the overall IH rate was 3.3 %. Hernia rates were 2.5 % for subcostal margin, 2.9 % for midline, and 5.5 % for other incisions (p = 0.006). Median time to hernia detection was 492 days. Factors associated with IH were increased weight, abdominal depth/girth, male sex, spleen size, visceral fat, and body height (p ≤ 0.04 for all), but not type of resection, prior operations, underlying diagnosis, weight loss, adjuvant chemotherapy or radiation, incision length or suture to incision ratio.

Conclusions

The described technique leads to a low IH rate of <3 % in subcostal or midline incisions, and can be recommended for routine use. The observed results appear superior to those of the STITCH trial, even for the smaller midline incision cohort.

Incisions in Hepatobiliopancreatic Surgery: Surgical Anatomy and its Influence to Open and Close the Abdomen

Incisions performed for hepato-pancreatic-biliary (HPB) surgery are diverse, and can be a challenge both to perform correctly as well as to be properly closed. The anatomy of the region overlaps muscular layers and has a rich vascular and nervous supply. These structures are fundamental for the correct functionality of the abdominal wall. When performing certain types of incisions, damage to the muscular or neurovascular component of the abdominal wall, as well as an inadequate closure technique may influence in the development of long-term complications as incisional hernias (IH) or bulging. Considering that both may impair quality of life and that are complex to repair, prevention becomes essential during these procedures. With the currently available evidence, there is no clear recommendation on which is the better incision or what is the best method of closure. Despite the lack of sufficient data, the following review aims to correlate the anatomical knowledge learned from posterior component separation with the incisions performed in hepato-pancreatic-biliary (HPB) surgery and their consequences on incisional hernia formation. Overall, there is data that suggests some key points to perform these incisions: avoid vertical components and very lateral extensions, subcostal should be incised at least 2 cm from costal margin, multilayered suturing using small bites technique and consider the use of a prophylactic mesh in high-risk patients. Nevertheless, the lack of evidence prevents from the possibility of making any strong recommendations.

Is the incision type important for the development of hernia in liver transplant patients?

OBJECTIVE

In this study, we aimed to investigate the rates and causes of incisional hernia that developed in the postoperative follow-up of patients who underwent liver transplantation.

MATERIAL AND METHOD

The results of patients who underwent LT by using three different incisions at the İstanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital organ transplant center between January 2015 and December 2019 were retrospectively analyzed. Patients were divided into Chevron (group-1), reverse T (group-2), and J incisions (group-3) and hernia development rates were examined.

RESULTS

There was no significant difference in terms of incisional hernia in groups 1 and 2 according to the incision type (p = .723). Incisional hernia rate was significantly lower in the J incision group (p < .001). When the factors that increase the development of hernia in all LT patients were examined, it was seen that male gender (p = .021), high BMI rate (p = .003), postoperative bleeding (p = .018), and wound infection (p = .039) caused a significant increase in risk.

CONCLUSION

The incision, which is made during liver transplant, is important for the development of hernia. The J incision has a low hernia development rate without causing access problems. Regardless of the incision, high BMI index, male gender, postoperative bleeding, and wound infection increase the development of incisional hernia in liver transplant patients.

Stepwise transversus abdominis muscle release for the treatment of complex bilateral subcostal incisional hernias

BACKGROUND

Management of subcostal incisional hernias is particularly complicated due to their proximity to the costochondral limits in addition to the lack of aponeurosis on the lateral side of the abdomen. We present our results of posterior component separation through the same previous incision as a safe and reproducible technique for these complex cases.

METHODS

We presented a multicenter and prospective cohort of patients diagnosed with bilateral subcostal incisional hernias on either clinical examination or imaging based on computed tomography from 2014 to 2020. The aim of this investigation was to assess the outcomes of abdominal wall reconstruction for subcostal incisional hernias through a new approach. The outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score.

RESULTS

A total of 46 patients were identified. All patients underwent posterior component separation. Surgical site occurrences occurred in 10 patients (22%), with only 7 patients (15%) requiring procedural intervention. During a mean follow-up of 18 months (range, 6-62 months), 1 (2%) case of clinical recurrence was registered. Also, there were 8 (17%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) of the postoperative scores compared with the preoperative score.

CONCLUSION

Posterior component separation technique for the repair of subcostal incisional hernias through the same incision is a safe procedure that avoids injury to the linea alba. It is associated with acceptable morbidity, low recurrence rate, and improvement in patients' reported outcomes.

How-we-do-it: the repair of postoperative ventral hernias after a Mercedes abdominal incision

PURPOSE

To describe the abdominal wall reconstruction technique with an Ultrapro mesh and outcome for the repair of postoperative ventral hernias after the use of a Mercedes incision during the initial abdominal operation.

METHOD

A retrospective review of all the patients undergoing elective postoperative ventral hernia repair between 2013 and 2019. The cohort of these patients that had an initial Mercedes incision was used for this study.

RESULTS

Fourteen patients met the criteria for this study. Thirteen of the patients were transplant patients (10 liver transplant and 3 combined pancreas and kidney transplant), and one patient was after a hepatectomy. Fifty-seven percent of these hernias were multiple defects. All the patients underwent the same repair of a modified Rives-Stoppa, transversus abdominis release, and a bilateral transverse plication. A partially absorbable Ultrapro mesh was used for all the patients, with two of the patients needing an additional Symbotex mesh in order to bridge a portion of the posterior fascia. There were 6 minor early postoperative complications (hematoma, superficial wound infection, and seroma) that did not require reoperation. Two patients were readmitted for observation of a wound hematoma, and two patients (14.2%) had recurrence during the follow-up period. The average length of hospitalization was 5.6 days.

CONCLUSION

This technique, with the use of an Ultrapro mesh, was found to be safe and effective for the repair of a postoperative ventral hernia due to an initial Mercedes incision.