Long-term follow-up results of umbilical hernia repair

Mesh versus suture for elective primary umbilical hernia open repair: a systematic review and meta-analysis

PURPOSE

Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR.

METHODS

We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%.

RESULTS

2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay.

CONCLUSION

The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs.

STUDY REGISTRATION

A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

Outcomes of Surgical Repair of Incisional Hernia in Patients With Severe and Morbid Obesity: A Comparative Study

Introduction Incisional hernia (IH) is a common complication after open and minimal access abdominal surgery. The current practice guidelines recommend weight reduction to achieve a body mass index (BMI) < 35 kg/m2 before surgical repair of ventral hernias. However, this could be challenging to achieve, especially in emergency presentations. This study aims to assess the safety of surgical repair of IH in patients with BMI ≥35 kg/m2. Methods A retrospective comparative study has been conducted to include all patients who had surgical repair of IH on an elective and emergency basis in a UK District General Hospital. The patients were divided into two groups. Group I BMI < 35 kg/m2 and Group II with BMI ≥35 kg/m2. A comparison was made between the two groups according to demographics, comorbidities, hernia characteristics, operative data, and outcomes. Results The study included 239 patients, 181 in Group I and 58 in Group II. Morbid obesity was associated with male patients, and they were younger than Group I, p= 0.001 and 0.013, respectively. 13.8% of Group I had DM compared to 29.3% in Group II, p= 0.007. There were no significant differences in hernia characteristics or mode of surgery between the two groups. However, Group II had more overall and wound-related complications, p= <0.001 each. There were no significant differences in 30-day and 90-day mortality, recurrence rate, or 90-day readmissions. Conclusions Surgical repair of IH in patients with severe and morbid obesity is associated with more overall and wound-related complications.

Umbilical hernia repair and recurrence: need for a clinical trial?

INTRODUCTION

Umbilical hernia repair, despite its perceived simplicity, is associated with recurrence between 2.7 and 27%, in mesh repair and non mesh repair respectively. Many factors are recognized contributors to recurrence however multiple defects in the linea alba, known to occur in up to 30% of patients, appear to have been overlooked by surgeons.

AIMS

This systematic review assessed reporting of second or multiple linea alba defects in patients undergoing umbilical hernia repair to establish if these anatomical variations could contribute to recurrence along with other potential factors.

METHODS

A systematic review of all published English language articles was undertaken using databases PubMed, Embase, Web of Science and Cochrane Library from January 2014 to 2019. The search terms 'Umbilical hernia' AND 'repair' AND 'recurrence' were used across all databases. Analysis was specified in advance to avoid selection bias, was registered with PROSPERO (154173) and adhered to PRISMA statement.

RESULTS

Six hundred and forty-six initial papers were refined to 10 following article review and grading. The presence of multiple linea alba defects as a contributor to recurrence was not reported in the literature. One paper mentioned the exclusion of six participants from their study due multiple defects. In all 11 factors were significantly associated with umbilical hernia recurrence. These included: large defect, primary closure without mesh, high BMI in 5/10 publications; smoking, diabetes mellitus, surgical site Infection (SSI) and concurrent hernia in 3/10. In addition, the type of mesh, advanced age, liver disease and non-closure of the defect were identified in individual papers.

CONCLUSION

This study identified many factors already known to contribute to umbilical hernia recurrence in adults, but the existence of multiple defects in the linea, despite it prevalence, has evaded investigators. Surgeons need to be consider documentation of this potential confounder which may contribute to recurrence.

Evaluation of Scientific Quality of YouTube Video Content Related to Umbilical Hernia

OBJECTIVE

Patients with umbilical hernias frequently refer to the YouTube videos to learn and perhaps apply traditional treatment methods. It is very difficult for these users to distinguish these videos as useful or harmful. In this study, we aimed to evaluate the scientific quality of YouTube video content on umbilical hernia.

METHODS

A total of 50 videos on YouTube pertaining to umbilical hernia were included in the study. All videos were evaluated by two experienced general surgeons. The uploader, video content, length, upload date, time since upload, number of views, numbers of comments, likes, and dislikes and Video Power Index (VPI) rates videos were recorded and evaluated. The videos were scored using the Quality Criteria for Consumer Health Information (DISCERN) and Global Quality Scale (GQS).

RESULTS

A total of 9,836 comments were made to the videos, 118,478 likes were made, and 15,009 dislikes were made. The mean DISCERN score given to the videos by the researchers was 2.57 ± 1.82 (min-max: 1-5) and the average GQS score was 2.62 ± 1.86. A statistically significant difference was found in terms of both DISCERN and GQS scores of videos uploaded by doctors compared to videos uploaded by nondoctors (p < 0.001). A statistically significant level of good agreement was found among investigators in terms of both DISCERN (p < 0.001, r = 0.778) and GQS (p < 0.001, r = 0.807) scores.  Conclusion: Videos with health content should definitely be uploaded by experts. Studies investigating the scientific quality of health videos uploaded on YouTube and similar platforms should be carried out continuously.

Proper Surgical Treatment of Small and Medium Size Umbilical Hernias. A Single Surgeon Experience

Introduction: Minimally invasive surgical procedures have become routine interventions nowadays and represent an effective therapeutic option even for small umbilical hernias, providing favorable postoperative and aesthetic results.

Aim of study: To determine the most appropriate minimally invasive treatment option for small and medium size umbilical hernias.

Materials and methods: We conducted a prospective study on 50 patients with small or medium umbilical hernia (<4 cm). All patients benefited of minimal invasive surgery with mesh implantation. Depending on the surgical procedure, two major groups were defined: group A – patients with open surgical approach (n = 24) and group B – patients undergoing laparoscopic surgery (n = 26). Clinical, surgical, postoperative, and follow-up data were analyzed.

Results: Mesh replacement via open approach through the umbilicus was associated with significantly reduced surgical time (p = 0.0359), administration of painkillers (p = 0.0461), and use of anticoagulants (p = 0.0404). Hospital stays (p = 0.0001) and costs (p = 0.0005) were also significantly lower in this group. After 6 months of follow-up, no recurrence was observed, and no significant differences were detected regarding postoperative pain and the patients’ professional reintegration. Patient satisfaction regarding postoperative scar was superior in the open group.

Conclusion: The present study indicates that the ventral patch technique is a safe and effective method for the treatment of small and medium size umbilical hernias.

Mesh versus suture in elective repair of umbilical hernia: systematic review and meta-analysis

BACKGROUND

Mesh repair of umbilical hernia has been associated with a reduced recurrence rate compared with suture closure, but potentially at the expense of increased postoperative complications and chronic pain. The objective of this systematic review and meta-analysis was to examine the outcomes after elective open mesh and suture repair for umbilical hernia in adults.

METHODS

A literature search was conducted to identify studies presenting original data on elective open mesh and suture repair of umbilical hernia. The primary outcome was hernia recurrence. Secondary outcomes included surgical-site infection (SSI), seroma, haematoma and chronic pain. Meta-analyses were undertaken.

RESULTS

The search resulted in 5353 hits and led to 14 studies being included (6 RCTs and 8 observational studies) describing a total of 2361 patients. Compared with suture, mesh repair was associated with a lower risk of recurrence (risk ratio (RR) 0·48, 95 per cent c.i. 0·30 to 0·77), with number needed to treat 19 (95 per cent c.i. 14 to 31). Mesh repair was associated with a higher risk of seroma (RR 2·37, 1·45 to 3·87), with number needed to harm 30 (17 to 86). There was no significant difference in the risk of SSI, haematoma or chronic pain.

CONCLUSION

The use of mesh in elective repair of umbilical hernia reduced the risk of recurrence compared with suture closure without altering the risk of chronic pain.

Is mesh always necessary in every small umbilical hernia repair? Comparison of standardized primary sutured versus patch repair: retrospective cohort study

Purpose

A retrospective analysis was carried out to compare the results of patch repair using ready-made, synthetic mesh (PR) and sutured repair (SR) based on standard protocols. The accumulated recurrence rate was accepted as the primary outcome. Pain at rest and during exercise, cosmetic effect and treatment satisfaction were chosen as the secondary endpoints.

Methods

Adult patients after elective, open surgical repair of a single, primary umbilical hernia < 2 cm in diameter were included. Patients with incarceration or strangulation, after previous umbilical hernia repair or other abdominal surgical interventions were excluded. In the SR group, single-layer sutures were placed using the short-stitch technique. In PR group, a 6.3-mm ready-made Parietene Ventral Patch (Medtronic) was used.

Results

161 patients (104 in PR and 57 in SR groups) were included in the study (22 months follow-up). Nine recurrences were observed [six in PR (5.8%) and three in SR group (5.2%)]. In PR group, three patients (2.9%) reported complaints at rest and none in SR group, while 18 patients (17.3%) in PR group reported pain during exercises and 7 (12.3%) in SR group.

Conclusion

For the smallest umbilical hernias, the use of dense fascia suturing (short-stitch technique) may be an effective alternative to patch repair techniques in patients with no additional risk factors for recurrence. The mesh patch repair method is associated with a significantly higher risk of postsurgical pain. Diastasis recti is a factor favoring umbilical hernia recurrence after both pure tissue repair and patch repair.

Tentacle-shaped mesh for fixation-free repair of umbilical hernias

Purpose

Mesh fixation and broad overlap represent an open issue in umbilical hernia repair. A proprietary-designed implant with tentacle straps at its boundary has been developed to ensure a suture-free repair and a broader coverage of the abdominal wall. The study describes the results of umbilical hernia procedures carried out with the tentacle-shaped implant and the related surgical technique.

Methods

A proprietary tentacle-shaped flat mesh having a central body with integrated radiating arms at its edge was used to repair large umbilical hernias in 62 patients. The implant was placed in preperitoneal sublay. The friction of the straps, crossing the abdominal wall thanks to a special needle passer, was intended to assure adequate grip to hold the implant in place assuring a fixation-free procedure and broad overlap of the hernia defect.

Results

In a mean follow-up of 48 months (range 10–62 months), 4 seromas and 2 ischemia of the navel skin occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence has been reported.

Conclusions

The tentacle strap system of the prosthesis effectively ensured an easier implant placement avoiding the need for suturing the mesh. The arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences even in the long term.

Hernia and Cancer: The Points Where the Roads Intersect

Introduction: This review aimed to present common points, intersections, and potential interactions or mutual effects for hernia and cancer. Besides direct relationships, indirect connections, and possible involvements were searched. Materials and Methods: A literature search of PubMed database was performed in July 2018 as well as a search of relevant journals and reference lists. The total number of screened articles was 1,422. Some articles were found in multiple different searches. A last PubMed search was performed during manuscript writing in December 2018 to update the knowledge. Eventually 427 articles with full text were evaluated, and 264 included, in this review. Results: There is no real evidence for a possible common etiology for abdominal wall hernias and any cancer type. The two different diseases had been found to have some common points in the studies on genes, integrins, and biomarkers, however, to date no meaningful relationship has been identified between these points. There is also some, albeit rather conflicting, evidence for inguinal hernia being a possible risk factor for testicular cancer. Neoadjuvant or adjuvant therapeutic modalities like chemotherapy and radiotherapy may cause postoperative herniation with their adverse effects on tissue repair. Certain specific substances like bevacizumab may cause more serious complications and interfere with hernia repair. There are only two articles in PubMed directly related to the topic of "hernia and cancer." In one of these the authors claimed that there was no association between cancer development and hernia repair with mesh. The other article reported two cases of squamous-cell carcinoma developed secondary to longstanding mesh infections. Conclusion: As expected, the relationship between abdominal wall hernias and cancer is weak. Hernia repair with mesh does not cause cancer, there is only one case report on cancer development following a longstanding prosthetic material infections. However, there are some intersection points between these two disease groups which are worthy of research in the future.

Is the 8-mm robotic port safe? A case of trocar site hernia after robotic cholecystectomy using the da Vinci Xi system

With the increase in the frequency of robotic surgery, complications have also increased, including trocar site hernias, which rarely occur at the 8-mm port site after robotic cholecystectomy using the da Vinci Xi system. A 37-year-old woman was diagnosed with cholecystitis on abdominal sonography. She underwent robotic cholecystectomy using a bikini-line incision. However, after postoperative day 2, she presented to the emergency room with small bowel obstruction secondary to a herniated bowel loop through the left 8-mm port site. After failure to resolve the ileus, the patient underwent emergency surgery, and bowel resection and anastomosis of the ischemic area were performed. After surgery, the patient was discharged without complications. Although hernias develop less commonly at 8-mm robotic port sites, surgeons should carefully close the ports, especially in cases with large fascial defects or a high risk of herniation.