Hernia recurrence as a problem of biology and collagen

Prevalence of rectus diastasis is higher in patients with inguinal hernia

PURPOSE

To determine the prevalence of rectus diastasis (RD) in patients with inguinal hernia.

MATERIAL AND METHODS

Multicenter, cross-sectional study. Patients with inguinal hernia were included in the study group (IH) and those with benign proctologic complaints created the control group (CG). Age, gender, BMI, family history for inguinal hernias, comorbid diseases, alcohol use, smoking, constipation, malignancy, chemotherapy, number of births, multiple pregnancies and prostate hypertrophy history of all patients in both groups were recorded. All patients were evaluated for RD and umbilical hernias by physical examination.

RESULTS

A total of 528 consecutive patients were included in the study (292 IH / 236 CG). Overall prevalence of RD was 35.6% and it was significantly higher in IH than in CG (46.9% vs 21.6%, p < 0.001). Also, umbilical hernia was more frequently detected in the patients with inguinal hernia. Other risk factors for RD were age, BMI, DM, BPH and smoking. The mean inter-rectus distance for 528 patients was 18.1 mm; it was 20.71 ± 10.68 mm in IH and 14.88 ± 8.82 in CG (p < 0.001). It was determined that the increase in age and BMI caused an increase in the inter-rectus distance, and that the presence of DM, inguinal hernia and umbilical hernia increased the inter-rectus distance quantitatively.

CONCLUSIONS

The prevalence of RD seems to be higher in patients with inguinal hernia comparing to that in general population. Increased age, high BMI and DM were found to be independent risk factors for RD development.

Matrix Metalloproteinase-2, COL1A1, and COL3A1 mRNA Expression in Aponeurosis Musculus obliquus Externus Abdominis of Adult Inguinal Hernias

BACKGROUND: The ratio change of type I and type III collagen in the peritoneal tissue can be associated with defects in collagen synthesis caused by the extracellular matrix’s degradation. Matrix metalloproteinase-2 (MMP-2) is an enzyme that contributes primarily to the degradation of this extra cell. AIM: This study aimed to analyze the differences in expression of COL1A1, COL3A1, and MMP-2 mRNA and the relationship between these expressions in adult inguinal hernias and the expression ratio between the COL1A1/COL3A1 genes. METHODS: This study was an observational study with a cross-sectional comparative study design, where the sample was adult inguinal hernia patients who were taken from the aponeurosis tissue m. external obliquus performed at the time of surgery, while control was a non-herniated patient. The sample RNA was isolated, followed by cDNA synthesis, and examined by real-time polymerase chain reaction. RESULTS: The mean values of expression for COL1A1, COL3A1, and MMP-2 in the case group were 40.02 ± 181.38 copy number, 33.70 ± 143.62 copy number, and 31.78 ± 84.47 copy number. Meanwhile, the expression values for COL1A1, COL3A1, and MMP-2 in the control group were 40.247 ± 162.837 copy number, 13.35 ± 37.43 copy number, and 20.58 ± 48.95 copy number. CONCLUSIONS: Our study showed a difference in COL3A1 expression between the hernia and non-hernia groups, and no difference was found in the expression of COL1A1 and MMP2 between the hernia and non-hernia groups.

Permanent end-colostomy parastomal hernia prevention using a novel three-dimensional mesh

PURPOSE

Prophylactic mesh placement has been proposed to reduce the high occurrence of parastomal hernia (PSH) after stoma formation.

METHODS

This is an observational study comparing two cohorts of patients: a mesh prophylaxis group (who received mesh prevention since introduction at our Institution) and a no mesh prophylaxis group (retrospectively selected from our historical series). Same exclusion criteria were applied for both groups. The study was conducted at a tertiary referral center for colorectal surgery. 43 patients were operated with mesh prophylaxis between May 2015 and may 2019. 45 patients underwent end-colostomy formation without prophylaxis between April 2011 and April 2015. The primary outcome measure was PSH development at 12-month follow up.

RESULTS

Demographic variables and risk factors for PSH were comparable between the two groups. There was no difference between the two cohorts in terms of operative time and main early postoperative outcomes. 37 patients completed the 12-month follow up in each group. PSH occurrence after 12-months was 11% in the mesh prophylaxis group and 54% in the no mesh prophylaxis group (p < 0.0001). There were no differences in long-term complications. 5% of patients who received mesh prophylaxis underwent emergency surgery for bowel occlusion at 7 and 10 months after surgery, with partial or complete mesh removal. At multivariate analysis, mesh prophylaxis was a protective factor for PSH development at 12 months (p < 0.0001).

CONCLUSIONS

Prophylactic intraperitoneal mesh placement appears to be effective in preventing PSH.

The darn technique for small (< 2 cm diameter) midline hernias

PURPOSE

Primary midline hernias arising in the linea alba are common. While mesh repair has been shown to reduce recurrence rates even in small hernias, many surgeons still use a suture repair for defects of less than 2 cm. The recent European and Americas Hernia Societies Guidelines recommended suture repair only for hernias smaller than 1 cm. A suture repair implies edge-to-edge or overlapping fascial margins, which necessarily involves tension on the repair. A darn is a tension-free repair where, in effect, a "mesh" is hand-woven across the defect in situ.

METHODS

The darn repair is a modification of the darn techniques for inguinal hernia repair. Eligible patients undergoing this repair at the Royal Infirmary of Edinburgh between 1 January 2008 and 31 December 2017 were identified from a prospective computer-based medical record system and their case notes reviewed. Inclusion criteria were adult patients with a primary midline abdominal wall defect smaller than 2 cm in the widest diameter of the hernia defect measured intra-operatively. Patients were followed up by telephone in 2019. Those who reported possible recurrence or other symptoms in the region of their hernia repair were reviewed in the outpatient clinic.

RESULTS

47 suture-darn repairs were undertaken over the 10-year period. Fifteen of the darn repair operations (32%) were performed under local anaesthesia. Forty-one patients were followed up with a mean of 80 ± 35 and median of 87 months after surgery. Six patients (13%) were lost to follow-up. Recurrence was found in two cases (5%) and one patient has since been diagnosed with a new epigastric hernia some 5 cm cranial to the previous repair.

CONCLUSIONS

The darn repair for small primary midline hernias is quick and inexpensive with promising long-term results. It can be performed under local anaesthesia. It can serve as an alternative to mesh repair for defects less than 2 cm in maximum dimension.

Hernia Repair Strength Enhanced With Antioxidants

BACKGROUND

Incisional hernia is one of the most common complications of abdominal surgery, and repairs are associated with significant recurrence rates. Mesh repairs are associated with the best outcomes, but failures are not uncommon. Doxycycline has been demonstrated to enhance mesh hernia repair outcomes with associated increases in collagen deposition and improved tensiometric strength. This study compares the outcomes of incisional hernia repair with doxycycline administration and the antioxidant tempol.

MATERIALS AND METHODS

Twenty-eight male Sprague Dawley rats underwent a midline hernia creation and an intraabdominal polypropylene mesh repair. The animals were administered saline, doxycycline, tempol, or both, daily for 8 wk. The abdominal wall was harvested at 8 wk and tensiometric strength and biochemical analysis was performed.

RESULTS

The tensiometric strength of the repair was increased in all experimental groups. Collagen type 1 deposition was increased, and collagen type 3 deposition was decreased in each of the experimental groups relative to control. There was no difference in MMP-2 and MMP-9 levels between control and experimental groups.

CONCLUSIONS

The hernia repair strength is equally enhanced with the administration of doxycycline or tempol. Dual therapy provided no benefit over treatment with either single agent. All treatment groups had an increase in collagen type 1:3 ratios, but the mechanism is not well understood. The benefits of antioxidant treatment following hernia repair are similar to treatment with doxycycline. Given the high frequency of incisional hernia repair failures, this study has implications for improving outcomes following ventral hernia repair through the use of either doxycycline or antioxidant therapy.

Complications and recurrence rates of patients with Ehlers-Danlos syndrome undergoing ventral hernioplasty: a case series

Purpose

Ventral hernia repair is one of the most frequently performed surgical procedures, though recurrences are common. Recurrence can be caused by impaired collagen formation or maturation; hence, patients with Ehlers-Danlos syndrome (EDS) are potentially at increased risk for hernia recurrence. EDS causes altered collagen metabolism, though little is known about the influence of EDS on ventral hernioplasty outcomes. This study aims to analyze these patients to report complication rates, recurrence rates, and, if possible, to give recommendations for surgical intervention.

Methods

A retrospective analysis between January 2000 and January 2017 was performed in a university hospital Belgium (UZ Ghent). Data on baseline characteristics, primary surgery, and hernias were extracted from patients’ medical charts. Noted endpoints were postoperative complications and recurrences.

Results

Fourteen patients (50% males) were included. Ten (71%) had an incisional hernia and four (29%) had a primary ventral hernia. Median age was 45 years (IQR 37.75–52.75), median BMI was 24.82 (IQR 22.43–26.87). Four patients (29%) smoked, one patient (7.1%) had diabetes mellitus, and five patients (36%) had an aneurysm of the abdominal aorta. All patients underwent elective open hernioplasty with mesh reinforcement. Three patients (21%) had a postoperative complication (two infections, one seroma). Recurrence rate was 7.1% (one patient).

Conclusions

This series describes 14 patients with a median follow-up of 50 months and a recurrence rate of 7.1%. The low recurrence rate could be explained by the use of large meshes that reinforce the entire midline to compensate for the reduced collagen strength in EDS patients.

Hernias- Is it a primary defect or a systemic disorder? Role of collagen III in all hernias- A case control study

Introduction

The need of this study is to assess the role of collagen III in all hernias which include primary inguinal hernias ventral and recurrent abdominal hernias.

Collagen type III represents the mechanically instable, less cross-linked collagen synthesized during the early days of wound healing. Quantitative assessment of collagen III in scar tissue on transversalis fascia as tissue obtained from cases operated for various hernias and compared to that of patients operated for abdominal surgeries for indications other than hernia was compared.

Materials and methods

In this study we had a total of 90 patients, of which 45 patients underwent mesh repair for the various hernias and 45 patients who underwent laparotomies for various reasons were included as controls. Size of 1 × 1cm transversalis fascia was taken in both subjects and was sent for quantitative assessment using Immunohistochemistry test. All the above cases were randomized as per age,sex,BMI, co morbidities and materials used for repair.

Results

Results were analysed quantitatively and classified into following groups:Based on intensity of staining into Mild, Intermediate and Well stained and based on Quantity of Collagen III into Grade 0---NIL, Grade 1--1-25%, Grade 2-26-50%, Grade 3--51-75%, Grade 4--76-100% (Table 1). In the case group we had 52.4%,35.7% and 11.9% of the cases in Grade 4, Grade 3 and Grade 2 which proved that there was increased presence of Collagen 3, where as 84.4%,4.4% and 11.1% of patients in the control group were classified as Grade 1, Grade 2, Grade 0. For the quantitative study -Chi square test value −81.279 and the p value < 0.001. For the intensity of staining -Chi square test value −57.64 and p value is < 0.001.

Conclusion

This study signifies that ventral, recurrent and primary inguinal hernias are not just caused because of a primary defect but an acquired disorder with respect to collagen distribution.

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Collagen III.

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Quantitative study.

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Grade and intensity of staining.

Prevention of parastomal hernias with 3D funnel meshes in intraperitoneal onlay position by placement during initial stoma formation

PURPOSE

In patients with terminal ostomies, parastomal hernias (PSHs) occur on a frequent basis. They are commonly associated with various degrees of complaints and occasionally lead to life-threatening complications. Various strategies and measures have been tested and evaluated, but to date there is a lack of published evidence with regard to the best surgical technique for the prevention of PSH development.

METHODS

We conducted a retrospective analysis of prospectively collected data of eighty patients, who underwent elective permanent ostomy formation between 2009 and 2014 by means of prophylactic implantation of a three-dimensional (3D) funnel mesh in intraperitoneal onlay (IPOM) position.

RESULTS

PSH developed in three patients (3.75%). No mesh-related complications were encountered and none of the implants had to be removed. Ostomy-related complications had to be noted in seven (8.75%) cases. No manifestation of ostomy prolapse occurred. Follow-up time was a median 21 (range 3-47) months.

CONCLUSION

The prophylactical implantation of a specially shaped, 3D mesh implant in IPOM technique during initial formation of a terminal enterostomy is safe, highly efficient and comparatively easy to perform. As opposed to what can be achieved with flat or keyhole meshes, the inner boundary areas of the ostomy itself can be well covered and protected from the surging viscera with the 3D implants. At the same time, the vertical, tunnel-shaped part of the mesh provides sufficient protection from an ostomy prolapse. Further studies will be needed to compare the efficacy of various known approaches to PSH prevention.

Laparoscopic ventral hernia repair: outcomes in primary versus incisional hernias: no effect of defect closure

PURPOSE

Supposing divergent aetiology, we found it interesting to investigate outcomes between primary (PH) versus incisional (IH) hernias. In addition, we wanted to analyse the effect of defect closure and mesh fixation techniques.

METHODS

37 patients with PH and 70 with IH were enrolled in a prospective cohort-study, treated with laparoscopic ventral hernia repair (LVHR) and randomised to ± transfascial sutures. In addition, we analysed results from a retrospective study with 36 PH and 51 IH patients. Mean follow-up time was 38 months in the prospective study and 27 months in the retrospective study.

RESULTS

35 % of PH's and 10 % of IH's were recurrences after previous suture repair. No late infections or mesh removals occurred. Recurrence rates in the prospective study were 0 vs. 4.3 % (p = 0.55) and the complication rates were 16 vs. 27 % (p = 0.24) in favour of the PH cohort. The IH group had a mesh protrusion rate of 13 vs. 5 % in the PH group (p = 0.32), and significantly (p < 0.01) larger hernias and adhesion score, longer operating time (100 vs. 79 min) and admission time (2.8 vs. 1.6 days). Closure of the hernia defect did not influence rate of seroma, pain at 2 months, protrusion or recurrence. An overall increased complication rate was seen after defect closure (OR 3.42; CI 1.25-9.33).

CONCLUSIONS

With PH, in comparison to IH treated with LVHR, no differences were observed regarding recurrence, protrusion or complication rates. Defect closure (raphe), when using absorbable suture, did not benefit long-term outcomes and caused a higher overall complication rate. (ClinicalTrials.gov number: NCT00455299).

Parastomal hernia repair and reinforcement: the role of biologic and synthetic materials

Parastomal hernia is a prevalent problem and treatment can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is to perform parastomal hernia repair with mesh whenever possible. There exist multiple options for mesh reinforcement (biologic and synthetic) as well as surgical techniques, to include type of repair (keyhole and Sugarbaker) and position of mesh placement (onlay, sublay, or intraperitoneal). The sublay and intraperitoneal positions have been shown to be superior with a lower incidence of recurrence. This procedure may be performed open or laparoscopically, both having similar recurrence and morbidity results. Prophylactic mesh placement at the time of stoma formation has been shown to significantly decrease the rates of parastomal hernia formation.

Parastomal hernia repair with a 3-D mesh device and additional flat mesh repair of the abdominal wall

PURPOSE

Parastomal hernias (PSHs) have been a major clinical problem. The aim of this study was to evaluate a new method of PSH repair in combination with an additional flat mesh reinforcement of the abdominal wall.

METHODS

In a pilot case series, seven patients suffering from complex PSHs (≥5 cm diameter and/or recurrence) underwent surgery and were treated by intraperitoneal onlay technique (IPOM) with a synthetic 3-D funnel-shaped mesh implant. The demographics, perioperative, and follow-up data are presented in this report.

RESULTS

The surgical strategy varied between purely laparoscopic (n = 1), laparoscopically assisted (hybrid n = 3), or open techniques (n = 3) using original or suture-reconstructed mesh devices. The funnel mesh implantations in IPOM technique were combined with attached flat meshes in the appropriate position of the abdominal wall. No procedure-related complications occurred. The mean length of hospital stay was 12 days and the mean operating time was 171 min. No recurrence of PSH or incisional hernias was observed during a mean follow-up period of 12.3 months (range from 7 to 22).

CONCLUSION

The use of a 3-D mesh implant has so far shown to be a promising option in the treatment of primary and recurrent PSHs. Its use proved to be reasonable in both laparoscopic and open IPOM technique. PSHs were preferably repaired using the original, unmodified implant, but when we also found it safe to incise, place and then suture the mesh around the pre-existing ostomy.

Parastomal hernia repair

Occurrence of parastomal hernia is considered a near inevitable consequence of stoma formation, making their management a common clinical dilemma. This article reviews the outcomes of different surgical approaches for hernia repair and describes in detail the laparoscopic Sugarbaker technique, which has been shown to have lower recurrence rates than other methods. Also reviewed is the current literature on the impact of prophylactic mesh placement during ostomy formation.

Direct and recurrent inguinal hernias are associated with ventral hernia repair: a database study

BACKGROUND

A systemically altered connective tissue metabolism has been demonstrated in patients with abdominal wall hernias. The most pronounced connective tissue changes are found in patients with direct or recurrent inguinal hernias as opposed to patients with indirect inguinal hernias. The aim of the present study was to assess whether direct or recurrent inguinal hernias are associated with an elevated rate of ventral hernia surgery.

METHODS

In the nationwide Danish Hernia Database, a cohort of 92,457 patients operated on for inguinal hernias was recorded from January 1998 until June 2010. Eight-hundred forty-three (0.91 %) of these patients underwent a ventral hernia operation between January 2007 and June 2010. A multivariate logistic regression analysis was applied to assess an association between inguinal and ventral hernia repair.

RESULTS

Direct (Odds Ratio [OR] = 1.28 [95 % CI, 1.08-1.51]) and recurrent (OR = 1.76, [95 % CI, 1.39-2.23]) inguinal hernias were significantly associated with ventral hernia repair after adjustment for age, gender, and surgical approach (open or laparoscopic).

CONCLUSIONS

Patients with direct and recurrent inguinal herniation are more prone to ventral hernia repair than patients with indirect inguinal herniation. This is the first study to show that herniogenesis is associated with type of inguinal hernia.

Laparoscopic repair for recurrent incisional hernias: a single institute experience of 10 years

PURPOSE

The treatment of recurrent incisional hernias (RIH) has been associated with unsatisfactory postoperative (PO) morbidity and high failure rates. The aim of this study is to retrospectively investigate our single-center experience of laparoscopic repair (LR) for RIH.

METHODS

The case records of 69 patients with RIH who underwent LR in our institution between January 2002 and November 2011 were reviewed. The operative technique has been standardized and provides onlay placement of an ePTFE mesh fixed with titanium tacks. Patients' demographic data and comorbidities, intraoperative course, PO complications and recurrences at follow-up were systematically collected and analyzed. The influence of defect's size and obesity variables on clinical outcomes was also investigated.

RESULTS

The mean operative time was 147.6 ± 71.2 min and mean hospital stay was 5.8 ± 1.8 days. No conversion occurred while five intraoperative complications (7.2 %) were recorded: three bowel injuries treated by laparoscopic sutures, one omentum bleeding and one epigastric vessel lesion. PO mortality was null, while overall morbidity was 13 % (9 patients) with a prevalence of seroma lasting over 8 weeks in six patients (8.7 %). Along a mean follow-up of 41 months (range 6-119), recurrence rate was 5.7 % (4 patients). Univariate analysis for width of defects and BMI showed no significant influence on patients' outcomes.

CONCLUSIONS

Surgical treatment for RIH remains controversial because of lack in literature of specific studies on this topic. Morbid obesity and large defects have been often associated with technical difficulties and worse results. Our 10 years' experience with LR provided satisfactory results in terms of PO morbidity and recurrence rate, despite any kind of patient selection.