Minimally invasive repair of ventral hernia with one third of tackers and fibrin glue: less pain and same recurrence rate

Laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique versus intraperitoneal onlay mesh (IPOM plus) for ventral hernia repair: a comparative analysis

PURPOSE

Primary aim of this study is to compare the postoperative outcomes of the laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique to the intraperitoneal onlay mesh closing the defect (IPOM plus), in terms of recurrence and bulging rates at one-year follow-up; secondary aim is to compare the postoperative complications, seroma and pain at 30 days and one-year after surgery.

METHODS

Patients with midline ventral hernia of 4-10 cm in width were included. Computed tomography scan was performed before, 1 and 12 months after surgery. Pain was evaluated using the visual analogue scale.

RESULTS

Forty-five and forty-seven consecutive patients underwent LIRA and IPOM plus, respectively. Preoperatively, smoke habits and chronic obstructive pulmonary disease rates were statistically significantly higher in the LIRA group (p = 0.0001 and p = 0.012, respectively). Two bulgings (4.4%) occurred in the LIRA group, while in the IPOM plus group occurred 10 bulgings (21.3%) and three recurrences (6.4%) (p = 0.017 and p = 0.085, respectively). Postoperatively, seven (15.6%, Clavien-Dindo I) and four complications (8.5%, two Clavien-Dindo I, two Clavien-Dindo III-b) occurred in the LIRA and in the IPOM plus group, respectively (p = 0.298). One month after surgery, clinical seroma, occurred in five (11.1%) and eight patients (17%) in the LIRA and in the IPOM plus group, respectively (p = 0.416). During follow-up, pain reduction occurred, without statistically significant differences.

CONCLUSIONS

In this study, even if we analysed a small series, LIRA showed lower bulging and recurrence rates in comparison to IPOM plus at one-year follow-up. Further prospective studies, with a large sample of patients and longer follow-up are required to draw definitive conclusions.

Primary closure of the midline abdominal wall defect during laparoscopic ventral hernia repair: analysis of risk factors for failure and outcomes at 5 years follow-up

BACKGROUND

The primary aim of this prospective study is to report bulging and recurrence rates and to analyze the risk factors responsible for failure, after laparoscopic ventral hernia repair (LVHR) with primary closure of defect (PCD) using a running suture and intraperitoneal mesh placement, at 5-year follow-up. The secondary endpoint is to evaluate 30-day postoperative complications, seroma, and pain.

METHODS

PCD failure was defined as the presence of postoperative bulging and/or recurrence. Pain was evaluated using a visual analogue scale (VAS). After surgery, fifty-eight patients underwent clinical examination and computed tomography scan to diagnose bulging, recurrence, and seroma (classified according to the Morales-Conde classification).

RESULTS

At 60 months follow-up, recurrence was observed in five patients (8.6%), while bulging, not needing a surgical treatment, occurred in fifteen patients (25.9%). Chronic obstructive pulmonary disease (COPD) is the only risk factor responsible for both outcomes together, bulging and recurrences (p = 0.029), while other considered risk factors as gender, age, body mass index, diabetes, smoke habits, primary or incisional hernia and the ratio defect width/transverse abdominal axis did not achieve the statistically significance. Clinical seroma was diagnosed at one month in eight patients (13.8%). Seromas were observed at one year of follow-up. During the follow-up, pain reduction occurred.

CONCLUSION

LVHR has evolved toward more anatomical concepts, with the current trend being the abdominal wall anatomical reconstruction to improve its functionality, reducing seroma rates. Based on results obtained, PCD is a reliable technique with excellent recurrence rate at 5 years follow-up, even when the defect closure may generate tension at the midline. On the other hand, this tension could be related with high bulging rate at long-term, particular in case of patients with COPD.

Fibrin glue does not promote migration and proliferation of bone marrow derived mesenchymal stem cells in collagenic membranes: an in vitro study

During Autologous Matrix-Induced Chondrogenesis (AMIC), the membrane is often glued into the chondral defect. However, whether fibrin glue influences cells proliferation and migration remain unclear. This study evaluated the impact of fibrin glue addition to biologic membranes loaded with bone marrow-derived mesenchymal stem cells (B-MSCs). A porcine derived collagen membrane (Cartimaix, Matricel GmbH, Germany) was used. B-MSCs were harvested from three different unrelated donors. The membranes were embedded in mounting medium with DAPI (ABCAM, Cambridge, UK) and analysed at 1-, 2-, 3-, 4-, 6-, and at 8-week follow-up. The DAPI ties the DNA of the cell nucleus, emitting blue fluorescence. DAPI/nuclei signals were analysed with fluorescence microscopy at 100-fold magnification. The group without fibrin glue demonstrated greater migration of the B-MSCs within the membrane at week 4 (P < 0.001), 6 (P < 0.001), and 8 (P < 0.001). No difference was found at week 1, 2, and 3. The group without fibrin glue demonstrated greater proliferation of B-MSCs within the membrane. These differences were significant at week 1 (P = 0.02), 2 (P = 0.008), 3 (P = 0.0009), 4 (P < 0.0001), 6 (P < 0.0001), 8 (P < 0.0001). Concluding, in the present setting, the use of fibrin in a collagenic biomembrane impairs B-MSCs proliferation and migration in vitro.

Fixation of the Membrane during Matrix-Induced Autologous Chondrocyte Implantation in the Knee: A Systematic Review

Introduction: It is unclear whether the type of membrane used for matrix-assisted autologous chondrocyte implantation (mACI) influences results. A systematic review was conducted to investigate the midterm results of the three most common types of membrane fixation for mACI. Methods: This systematic review was conducted according to the 2020 PRISMA checklist. PubMed, Google Scholar, Embase, and Scopus online databases were accessed in August 2022. All the prospective clinical trials reporting outcomes of mACI in the knee were considered. Studies that describe the modality of membrane fixation (glued, glued, and sutured, no fixation) used for mACI were eligible. Studies that conducted a minimum of 12 months of follow-up were considered. The outcomes of interest were the Tegner Activity Scale and International Knee Documentation Committee (IKDC) score. The rate of failure and revisions were also collected. Results: Data from 26 studies (1539 procedures; 554 of 1539 (36%) were women) were retrieved. The mean follow-up was 42.6 (12 to 84) months. No difference between the groups was found in terms of mean duration of symptoms, age, BMI, gender, and defect size (P > 0.1). No difference was found in terms of the Tegner score (P = 0.3). When no fixation was used, a statistically significant higher IKDC compared to the other groups (P = 0.02) was evidenced. No difference was found in the rate of failure (P = 0.1). The no-fixation group evidenced a statistically significant lower rate of revisions (P = 0.02). Conclusions: No membrane fixation for mACI in the knee scored better than the fastening techniques at the midterm follow-up.

Fibrin glue does not assist migration and proliferation of chondrocytes in collagenic membranes: an in vitro study

Background

Some authors secured the membrane during matrix-induced autologous chondrocyte implantation (mACI) with fibrin glue or did not use a formal fixation. The real impact of fibrin glue addition on chondrocytes migration and proliferation has not yet been clarified. This study evaluated the impact of fibrin glue on a chondrocyte loaded collagenic membrane.

Methods

A resorbable collagen I/III porcine derived membrane commonly employed in AMIC was used for all experiments. Chondrocytes from three difference donors were used. At 1-, 2-, 3-, 4-, 6-, and at 8-week the membranes were embedded in Mounting Medium with Dapi (ABCAM, Cambridge, UK). The Dapi contained in the mounting medium ties the DNA of the cell nucleus and emits a blue fluorescence. In this way, the spreading of the cells in the membrane can be easily monitored. The outcomes of interest were to evaluate (1) cell migration and (2) cell proliferation within the porous membrane layer. DAPI/nuclei signals were analysed with fluorescence microscope under a magnification of 100-fold.

Results

The no-fibrin group demonstrated greater migration of the cells within the membrane. Although migration resulted higher in the no-fibrin group at every follow-up, this difference was significant only at week 1 (P < 0.001), 2 (P = 0.004), and 3 (P = 0.03). No difference was found at week 3, 6, and 8. The no-fibrin group demonstrated greater proliferation of the chondrocytes within the membrane. These differences were significant at week 4 (P < 0.0001), 6 (P < 0.0001), 8 (P < 0.0001).

Conclusion

The use of fibrin glue over a resorbable membrane leads to lower in vitro proliferation and migration of chondrocytes.

Autologous matrix-induced chondrogenesis is effective for focal chondral defects of the knee

Focal chondral defects of the knee are common and their management is challenging. This study investigated the efficacy and safety of Autologous Matrix-Induced Chondrogenesis (AMIC) for focal chondral defects of the knee. A systematic review and meta-analysis was conducted (according to the 2020 PRISMA statement) to investigate the efficacy of AMIC in improving symptoms and to compare AMIC versus microfracture (MFx). In January 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar, Embase. No time constrain was used for the search. All the clinical trials investigating AMIC and/or those comparing AMIC versus MFx for focal chondral defects of the knee were accessed. Only studies published in peer reviewed journals were considered. Studies which investigated other locations of the defects rather than knee were not eligible, nor those reporting data form mixed locations. Studies which reported data on revision settings, as well as those investigating efficacy on kissing lesions or multiple locations, were not suitable. The mean difference (MD) and odd ratio (OR) effect measure were used for continuous and binary data, respectively. Data from 18 studies (548 patients) were retrieved with a mean follow-up of 39.9 ± 26.5 months. The mean defect size was 3.2 ± 1.0 cm². The visual analogue scale (VAS) decreased of − 3.9/10 (95% confidence interval (CI) − 4.0874 to -3.7126), the Tegner Activity Scale increased of + 0.8/10 (95% CI 0.6595 to 0.9405). The Lysholm Knee Scoring System increased of + 28.9/100 (95% CI 26.8716 to 29.1284), as did the International Knee Documentation Committee (IKDC) + 33.6/100 (95% CI 32.5800 to 34.6200). At last follow-up no patient showed signs of hypertrophy. 4.3% (9 of 210) of patients underwent revision procedures. The rate of failure was 3.8% (9 of 236). Compared to MFx, AMIC demonstrated lower VAS score (MD: − 1.01; 95% CI − 1.97 to 0.05), greater IKDC (MD: 11.80; 95% CI 6.65 to 16.94), and lower rate of revision (OR: 0.16; 95% CI 0.06 to 0.44). AMIC is effective for focal chondral defects of the knee. Furthermore, AMIC evidenced greater IKDC, along with a lower value of VAS and rate of revision compared to MFx.

Membrane scaffolds for matrix-induced autologous chondrocyte implantation in the knee: a systematic review

INTRODUCTION

Chondral defects of the knee are common and their management is challenging.

SOURCE OF DATA

Current scientific literature published in PubMed, Google scholar, Embase and Scopus.

AREAS OF AGREEMENT

Membrane-induced autologous chondrocyte implantation (mACI) has been used to manage chondral defects of the knee.

AREAS OF CONTROVERSY

Hyaluronic acid membrane provides better outcomes than a collagenic membrane for mACI in the knee at midterm follow-up is controversial.

GROWING POINTS

To investigate whether hyaluronic acid membrane may provide comparable clinical outcomes than collagenic membranes for mACI in focal defects of the knee.

AREAS TIMELY FOR DEVELOPING RESEARCH

Hyaluronic acid membrane yields a lower rate of failures and revision surgeries for mACI in the management of focal articular cartilage defects of the knee compared with collagenic scaffolds at midterm follow-up. No difference was found in patient reported outcome measures (PROMs). Further comparative studies are required to validate these results in a clinical setting.

Essential anatomical landmarks in placement of an adequate size mesh for a successful ventral hernia repair

Safe and effective hernia repair requires a surgeon to have the appropriate knowledge necessary to learn details of the surgical technique. Long-term results of treatment, even with the use of synthetic implants, have shown that recurrences were still a significant clinical problem concerning up to every fourth patient. Therefore, it was pointed out that the mere presence of synthetic material is not a solitary circumstance sufficient for a successful repair. A key finding in recurrence prevention has been to focus surgeons&apos; attention on the relationship between the size of the hernia orifice and the mesh surface. An optimal ratio of these values has not been established yet, however, it is considered that the mesh surface area should be at least sixteen times larger than the area of the abdominal wall defect. In cases of medium and large hernias, in order to place an extensive mesh sheet in the appropriate anatomical space of the abdominal wall, an extensive dissection needs to be performed, including several different compartments. Therefore, a surgeon undertaking a hernia repair needs to know perfectly the anatomy and function of all the myofascial structures involved. Performing an incorrect dissection of a mistaken structure may lead to catastrophic abdominal deformities. Depriving the patient of the natural support of the abdominal wall provided by the muscles may lead to total or partial destabilization of the trunk and lead to disability. In this paper a detailed description of anatomical structures and its practical use has been presented.