What Is the Current Knowledge About Sublay/Retro-Rectus Repair of Incisional Hernias?

Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias

INTRODUCTION

Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown.

METHODS

The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups.

RESULTS

In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013).

CONCLUSIONS

This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.

Open vs. minimally invasive sublay incisional hernia repair. Is there a risk of overtreatment? EVEREG registry analysis

INTRODUCTION

Incisional hernia (IH) is a very common surgical procedure. Registries provide real world data. The objective is to analyze the open and minimally invasive (MIS) sublay technique (with or without associated components separation [CS]) in IH cases from the EVEREG registry and to evaluate the evolution over time of the techniques.

METHODS

All patients in EVEREG from July 2012 to December 2021 were included. The characteristics of the patients, IH, surgical technique, complications and mortality in the first 30 days were collected. We analyzed Group 1 (open sublay vs MIS sublay, without CS), Group 2 (open sublay vs MIS sublay, with CS) and Group 3 where the evolution of open and MIS techniques was evaluated over time.

RESULTS

4867 IH were repaired using a sublay technique. Group 1: 3739 (77%) open surgery, mostly midline hernias combined (P = .016) and 55 (1%) MIS, mostly lateral hernias (LH) (P = .000). Group 2: 1049 (21.5%) open surgery and 24 (0.5%) MIS. A meaningful difference (P = .006) was observed in terms of transverse diameters (5.9 (SD 2.1) cm for the MIS technique and 10.11 (SD 4.8) for the open technique). The LH MIS associated more CS (P = .002). There was an increase in the use of the sublay technique over time (with or without CS).

CONCLUSION

Increased use of the sublay technique (open and MIS) over time. For some type of hernia (LH) the MIS sublay technique with associated CS may have represented an overtreatment.

No difference in outcomes between large- and small-pore meshes in a prospective, randomized, multicenter trial investigating open retromuscular meshplasty for incisional hernia repair

STUDY DESIGN

A randomized, controlled, prospective multicenter clinical trial with a parallel group design was initiated in eight surgical centers to compare a large-pore polypropylene mesh (Ultrapro®) to a small-pore polypropylene mesh (Premilene®) within a standardized retromuscular meshplasty for incisional hernia repair.

METHODS

Between 2004 and 2006, patients with a fascial defect with a minimum diameter of 4 cm after vertical midline laparotomy were recruited for the trial. Patients underwent retromuscular meshplasty with either a large-pore or a small-pore mesh to identify the superiority of the large-pore mesh. Follow-up visits were scheduled at 5 and 21 days and 4, 12, and 24 months after surgery. A clinical examination, a modified short form 36 (SF-36®), a daily activity questionnaire, and an ultrasound investigation of the abdominal wall were completed at every follow-up visit. The primary outcome criterion was foreign body sensation at the 12-month visit, and the secondary endpoint criteria were the occurrence of hematoma, seroma, and chronic pain within 24 months postoperatively.

RESULTS

In 8 centers, 181 patients were included in the study. Neither foreign body sensation within the first year after surgery (27.5% Ultrapro®, 32.2% Premilene®) nor the time until the first occurrence of foreign body sensation within the first year was significantly different between the groups. Regarding the secondary endpoints, no significant differences could be observed. At the 2-year follow-up, recurrences occurred in 5 Ultrapro® patients (5.5%) and 4 Premilene® patients (4.4%).

CONCLUSION

Despite considerable differences in theoretical and experimental works, we have not been able to identify differences in surgical or patient-reported outcomes between the use of large- and small-pore meshes for retromuscular incisional hernia repair.

TRIAL REGISTRATION

Clinical Trials NCT04961346 (16.06.2021) retrospectively registered.

Evaluation of the Sublay Mesh Repair Outcomes in Different Types of Ventral Hernia

Introduction: Ventral hernia repair is one of the challenging surgical operations over time. Several surgical techniques for mesh repair have been described (onlay, inlay, sublay, and underlay repairs). It is suggested that sublay mesh repair has the lowest recurrence and surgical site infection in open anterior abdominal hernia repair. This study aimed to analyze the pros and cons of the sublay mesh in ventral hernia repair to evaluate the significance of this technique as a treatment modality. Hospital stay, acute postoperative complications, and the recurrence rate were the main areas of investigation.

Methods: A retrospective study on 79 patients with ventral hernias who were operated on with sublay mesh repair between January 2015 and December 2018 was conducted. Patients were admitted through the elective route. The study included fit patients with first-time ventral hernias (primary and incisional). Recurrent hernia, patients with decompensated cardiopulmonary disorders, and bleeding disorders were excluded from the project. The project pro forma includes patient’s demographics, operative details, length of stay, postoperative complications, and follow-up up to 12 months.

Results: All patients underwent open mesh repair using the sublay technique. The ventral hernia was five times more common in females than males. The mean age of presentation was 44.8 years old. The mean operating time was 67 minutes and a one-day hospital stay. Paraumblical and incisional hernias represented the majority of cases. The component separation approach was added in three cases (3.7%). Simultaneous cholecystectomy was performed in two cases (2.5%). Only six cases (6.3%) developed wound-related complications, while two cases (2.5%) had a recurrence.

Conclusion: The sublay mesh repair is a perfect choice for the repair of ventral abdominal hernia. It is associated with a smooth and short hospital stay and the least incidence of complications and recurrence.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature.

METHODS

A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic.

RESULTS

In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification.

CONCLUSION

Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Imaging and Treatment of Complications of Abdominal and Pelvic Mesh Repair

Surgical mesh is used most frequently for tension-free repair of abdominal wall hernias in adults, because the rate of hernia recurrence is lower with mesh than with primary soft-tissue repair. Since the introduction of polypropylene mesh in the middle of the 20th century, many mesh materials and configurations for specific surgical procedures have been developed. In addition to abdominal wall hernia repair, mesh may be used for repair of diaphragmatic hernias, urinary incontinence in women (female slings), genitourinary prolapse (vaginal mesh and sacrocolpopexy), rectal prolapse (rectopexy), and postprostatectomy male urinary incontinence (male slings). General mesh repair complications include chronic pain; fluid collections such as seromas, hematomas, and abscesses; adhesions that may lead to intestinal blockage; erosion into solid or hollow viscera including enterocutaneous fistulizing disease; and mesh failure characterized by mesh shrinkage, detachment, and migration with repair malfunction. Several mesh complications are often diagnosed with imaging, primarily with CT and less frequently with MRI and US, despite variable mesh visibility at imaging. This article reviews the common surgical mesh applications in the abdomen and pelvis, discusses imaging of mesh repair complications, and provides complication treatment highlights.^©RSNA, 2020.

[Abdominal wall hernias part 2 : Operative treatment techniques]

In accordance with the guidelines suture procedures, a preperitoneal mesh technique, the laparoscopic intraperitoneal onlay mesh (IPOM) or the new minimally invasive techniques, i.e. the endoscopic mini/less open sublay (E/MILOS) technique, enhanced-view totally extraperitoneal (eTEP) repair and totally endoscopic sublay (TES) repair should be used for primary abdominal wall hernias (umbilical hernia, epigastric hernia) depending on the defect size and patient characteristics (obesity, rectus abdominis muscle diastasis). For incisional hernias the sublay operation and laparoscopic IPOM continue to be the techniques most commonly used, whereby laparoscopic IPOM is being increasingly replaced by the open sublay operation and the new techniques (E/MILOS, eTEP and TES). For defects greater than 10 cm posterior component separation with transversus abdominis muscle release is becoming increasingly more established. There are also abdominal wall hernias (recurrences, lateral and combined lateral and medial defects) necessitating an open IPOM or an onlay technique.

What is the outcome of the open IPOM versus sublay technique in the treatment of larger incisional hernias?: A propensity score-matched comparison of 9091 patients from the Herniamed Registry

INTRODUCTION

In an Expert Consensus guided by systematic review, the panel agreed that for open elective incisional hernia repair, sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. This analysis of data from the Herniamed Registry aimed to compare the outcomes of open IPOM and sublay technique.

METHODS

Propensity score matching of 9091 patients with elective incisional hernia repair and with defect width ≥ 4 cm was performed. The following matching variables were selected: age, gender, risk factors, ASA score, preoperative pain, defect size, and defect localization.

RESULTS

For the 1977 patients with open IPOM repair and 7114 patients with sublay repair, n = 1938 (98%) pairs were formed. No differences were seen between the two groups with regard to the intraoperative, postoperative and general complications, complication-related reoperations and recurrences. But significant disadvantages were identified for the open IPOM repair in respect of pain on exertion (17.1% vs. 13.7%; p = 0.007), pain at rest (10.4% vs. 8.3%; p = 0.040) and chronic pain requiring treatment (8.8% vs. 5.8%; p < 0.001), in addition to rates of 3.8%, 1.1% and 1.1%, respectively, occurring in both matched patients. No relationship with tacker mesh fixation was identified. There are only very few reports in the literature with comparable findings.

CONCLUSION

Compared with sublay repair, open IPOM repair appears to pose a higher risk of chronic pain. This finding concords with the Expert Consensus recommending that incisional hernia should preferably be repaired using the sublay technique.

Recurrent incisional hernia repair: surgical outcomes in correlation with body-mass index

BACKGROUND

Hernia recurrence rates after incisional hernia repair vary between 8.7 and 32%, depending on multiple factors such as patient characteristics, the use of meshes, surgical technique and the degree of experience of the treating surgeon. Recurrent hernias are considered complex wall hernias, and 20% of all incisional hernia repairs involve a recurrent hernia. The aim of this study was to investigate the outcomes after recurrent incisional hernia repair, in association with surgical technique and body-mass index (BMI).

METHODS

All patients who had incisional hernia repair between 2013 and 2018 were included. Primary outcome was rate of recurrent incisional hernia after initial hernia repair. Secondary outcomes were complication rate and recurrence rate in association with BMI.

RESULTS

A number of 269 patients were included, of which 75 patients (27.9%) with a recurrent incisional hernia. Recurrent hernia repair was performed in 49 patients, 83.7% underwent open repair. Complication rate for recurrent hernia repair was higher than for the initial incisional hernia repair. Of the 49 patients with recurrent hernia repair, patients with a BMI above 30 had higher complication and recurrence rates compared to patients with BMI below 30. Especially infectious complications were more common in patients with a higher BMI: 23.1% vs. 0% wound infections.

CONCLUSION

The results from this study show that complication and recurrence rates are increased after recurrent incisional hernia repair, which are further increased by obesity. Only a limited amount of literature is available on this topic, further larger multicenter studies are necessary, until then a patient-specific surgical approach based on the surgeon's expertise is recommended.

Is the sublay self-gripping mesh effective for incisional ventral hernia repair? Our experience and a systematic review of the literature

Sublay mesh repair seems to be the most effective method for treating incisional hernias (IHs). The aim of this study was to report our experience with retromuscular repair and self-gripping mesh for the treatment of midline IHs. In addition, we provided a systematic review of the literature regarding the use of this novel combination. All patients undergoing elective IH repair from June 2016 to November 2018 were included. The self-gripping mesh was placed in the sublay position. Demographic data, defect sizes, postoperative complications and follow-up durations were collected. A systematic review of the available literature was conducted in January 2020 using main databases. A total of 37 patients (20/17M/F) were included in this study, and the mean age and body mass index (BMI) were 58 years and 27 kg/m2, respectively. Minor complications occurred in six patients. Long-term follow-up demonstrated recurrence in three patients. Regarding the review, five publications were considered relevant. The highest complication rate was 28.6%, and the recurrence rate varied from 0 to 5.1%. This is the first review of the literature regarding sublay IH repair using a self-gripping mesh. The low rates of postoperative complications and recurrence in our experience and those reported by most of the reviewed articles demonstrate that this is a safe and effective method for repairing IHs.

Small and Laterally Placed Incisional Hernias Can be Safely Managed with an Onlay Repair

INTRODUCTION

In meta-analyses and systematic reviews, clear advantages have been identified for the sublay versus onlay technique for treatment of incisional hernias. Nonetheless, an expert panel has noted that the onlay mesh location may be useful in certain settings.

MATERIALS AND METHODS

First, unadjusted analysis of data from the Herniamed Registry was performed to compare 6797 sublay operations with 1024 onlay operations for repair of incisional hernias. Then, using propensity score matching to account for the influence of variables age, gender, ASA score, BMI, risk factors, preoperative pain, defect size, and defect localization, 1016 pairs were formed and compared with each other.

RESULTS

Unadjusted analysis revealed that the onlay operation was used significantly more often for small defects, lateral defect localization, and in women. After comparing the propensity score-matched pairs, no significant difference was found between the sublay and onlay technique in the outcome criteria intra- and postoperative complications, general complications, complication-related reoperations, pain at rest, pain on exertion, chronic pain requiring treatment, and recurrence on 1-year follow-up. But that was true only for this carefully selected patient collective.

CONCLUSION

In a selected patient collective with small and lateral incisional hernias and with a large proportion of women, outcomes obtained for the onlay and sublay techniques do not differ significantly.

Recurrent Incisional Hernia Repair-An Overview

Introduction: Recurrent incisional hernias with a rate of around 20% account for a relatively large proportion of all incisional hernias. It is difficult to issue any binding recommendations on optimum treatment in view of the relatively few studies available on this topic. This review now aims to collate the data available on recurrent incisional hernia. Material and Methods: A systematic search of the available literature was performed in January 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals and reference lists. For the present analysis, 47 publications were identified as relevant. Results: There are mainly case series available on the treatment of recurrent incisional hernia. Eight evaluable case series and two prospective comparative studies report on treatment of between 27 and 85 recurrent hernias. After primary open repair of incisional hernia and defect sizes of < 8-10 cm, the recurrence operation can be performed in laparoscopic technique provided the surgeon has sufficient experience in that procedure. That also applies to multiple recurrences after exclusively open repair. There are no evaluable data on a repeat laparoscopic approach after minimally invasive repair of primary incisional hernia. Such an approach should only be chosen by very experienced laparoscopic surgeons and based on a well-founded indication. Further data are urgently needed on treatment of recurrent incisional hernia. Conclusion: Very little data are available on the treatment of recurrent incisional hernia. Based on the tailored approach concept, a laparoscopic approach undertaken by an experienced laparoscopic surgeon can be recommended for recurrent hernias after primary open repair and for defects of up to 8-10 cm.

Onlay Technique in Incisional Hernia Repair-A Systematic Review

Introduction: A meta-analysis that compared the onlay vs. sublay technique in open incisional hernia repair identified better outcomes for the sublay operation. Nonetheless, an Expert Consensus Guided by Systematic Review found the onlay mesh location useful in certain settings. Therefore, all studies on the onlay technique were once again collated and analyzed.

Materials and Methods: A systematic search of the available literature was performed in August 2018 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library. For the present analysis 42 publications were identified as relevant.

Results: In five prospective randomized trials and 17 observational studies the postoperative complication rates ranged between 5 and 76%, with a mean value of 33.5%. The recurrence rates in these studies also ranged between 0 and 32%, with a mean value of 9.9%. Hence, compared with the literature data on the sublay operation, more post-operative complications, in particular wound complications and seroma, with a comparable recurrence rate, were identified.

Conclusion: When the onlay technique is used in certain settings for incisional hernia repair, a careful dissection technique and prophylactic measures (drainage, abdominal binders, fibrin sealant) should be employed to prevent wound complications and seroma formation.

Open Intraperitoneal Onlay Mesh (IPOM) Technique for Incisional Hernia Repair

In an Expert Consensus Guided by Systematic Review the panel agreed that for open elective incisional hernia repair sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. Accordingly, the available literature on the open IPOM technique was searched and evaluated. Material and Methods: A systematic search of the available literature was performed in July 2018 using Medline, PubMed, and the Cochrane Library. Forty-five publications were identified as relevant for the key question. Results: Compared to laparoscopic IPOM, the open IPOM technique was associated with significantly higher postoperative complication rates and recurrence rates. For the open IPOM with a bridging situation the postoperative complication rate ranges between 3.3 and 72.0% with a mean value of 20.4% demonstrating high variance, as did the recurrence rate of between 0 and 61.0% with a mean value of 12.6%. Only on evaluation of the upward-deviating maximum values and registry data is a trend toward better outcomes for the sublay technique demonstrated. Through the use of a wide mesh overlap, avoidance of dissection in the abdominal wall and defect closure it appears possible to achieve better outcomes for the open IPOM technique. Conclusion: Compared to the laparoscopic technique, open IPOM is associated with significantly poorer outcomes. For the sublay technique the outcomes are quite similar and only tendentially worse. Further studies using an optimized open IPOM technique are urgently needed.