Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A

Abstract

In 2014, the International Endohernia Society (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias.” Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.

Methods

For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included.

Results

Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques—minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields.

Conclusion

Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION

Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.

METHODS

A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.

RESULTS

The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.

CONCLUSION

The routine use of biologic and biosynthetic meshes cannot be recommended.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia

PURPOSE

Chronic inguinodynia is one of the most frequent complications after groin herniorrhaphy. We investigated the retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve to prevent direct nerve injury during hernia repairs and to find the most advantageous approach for posterior triple neurectomy.

METHODS

We dissected the inguinal nerves in 30 human anatomic specimens bilaterally. The distances from each nerve and their entry points in the abdominal wall were measured in relation to the posterior superior iliac spine, anterior superior iliac spine, and the midpoint between the two iliac spines on the iliac crest. We evaluated our findings by creating high-resolution summation images.

RESULTS

The courses of the iliohypogastric and ilioinguinal nerve are most consistent on the anterior surface of the quadratus lumborum muscle. The genitofemoral nerve always runs on the psoas muscle. The entry points of the nerves in the abdominal wall are located as follows: the iliohypogastric nerve is above the iliac crest and lateral from the anterior superior iliac spine, the ilioinguinal nerve is with great variability, either above or below the iliac crest and lateral from the anterior superior iliac spine, the genital branch is around the internal inguinal ring, the femoral branch is either cranial or caudal to the iliopubic tract, and the lateral femoral cutaneous nerve is either medial or lateral to the anterior superior iliac spine.

CONCLUSION

Nerve injury during inguinal hernia repairs can be avoided by taking the topographic anatomy of the inguinal nerves into consideration. The most advantageous plane to look for the iliohypogastric and ilioinguinal nerve during posterior neurectomy is on the anterior surface of the quadratus lumborum muscle. For the surgical treatment of severe chronic inguinodynia, especially after posterior open or endoscopic mesh repair (TAPP/TEP), the retroperitoneoscopic or open retroperitoneal approach for posterior triple neurectomy can be considered.

Laparoscopic IPOM versus open sublay technique for elective incisional hernia repair: a registry-based, propensity score-matched comparison of 9907 patients

BACKGROUND

For comparison of laparoscopic IPOM versus sublay technique for elective incisional hernia repair, the number of cases included in randomized controlled trials and meta-analyses is limited. Therefore, an urgent need for more comparative data persists.

METHODS

In total, 9907 patients with an elective incisional hernia repair and 1-year follow-up were selected from the Herniamed Hernia Registry between September 1, 2009 and June 1, 2016. Using propensity score matching, 3965 (96.5%) matched pairs from 4110 laparoscopic IPOM and 5797 sublay operations were formed for comparison of the techniques.

RESULTS

Comparison of laparoscopic IPOM versus open sublay revealed disadvantages for the sublay operation regarding postoperative surgical complications (3.4% vs. 10.5%; p < 0.001), complication-related reoperations (1.5% vs. 4.7%; p < 0.001), and postoperative general complications (2.5% vs. 3.7%; p = 0.004). The majority of surgical postoperative complications were surgical site infection, seroma, and bleeding. Laparoscopic IPOM had disadvantages in terms of intraoperative complications (2.3% vs. 1.3%; p < 0.001), mainly bleeding, bowel, and other organ injuries. No significant differences in the recurrence and pain rates at 1-year follow-up were observed.

CONCLUSION

Laparoscopic IPOM was found to have advantages over the open sublay technique regarding the rates of both surgical and general postoperative complications as well as complication-related reoperations, but disadvantages regarding the rate of intraoperative complications.

What are the trends in incisional hernia repair? Real-world data over 10 years from the Herniamed registry

INTRODUCTION

There is an increasingly controversial debate about the best possible incisional hernia repair technique. Despite the good outcomes of laparoscopic IPOM, concerns about the intraperitoneal mesh placement and its potential intraabdominal complications have risen. Against that background, this paper now analyzes changes and trends in incisional hernia repair techniques in the recent decade.

METHODS

Between 2010 and 2019 a total of 61,627 patients with primary elective incisional hernia repair were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves to visualize trends. The explorative Fisher's exact test was used for statistical calculation of significant differences. Since the number of cases entered into the Herniamed Registry for the years 2010-2012 was still relatively small, the years 2013 and 2019 were compared for statistical analysis.

RESULTS

In the analyzed time period, the proportion of incisional hernias repaired in open suture technique remained unchanged at about 10%. The proportion of laparoscopic IPOM repairs decreased significantly from 33.8% in 2013 to 21.0% (p < 0.001) in 2019. Conversely, the proportion of open sublay repairs increased significantly from 32.1% in 2013 to 41.4% (p < 0.001) in 2019. Starting in 2015, there has also been the introduction and increasing use (4.5% in 2013 vs. 10.0% in 2019; p < 0.001) of new minimally-invasive techniques with placement of a mesh into the sublay/retromuscular/preperitoneal abdominal wall layer (E/MILOS, eTEP, preperitoneal mesh technique).

CONCLUSION

Analysis of data from the Herniamed Registry shows a significant trend to the disadvantage of the laparoscopic IPOM and to the advantage of the open sublay operation and the new minimally-invasive techniques (E/MILOS, eTEP, preperitoneal mesh technique). Despite all the recommendations in the guidelines, 10% of incisional hernias continue to be treated by means of a suture technique.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project

INTRODUCTION

There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems.

METHODS

The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries.

RESULTS

The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center.

CONCLUSION

Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

Treatment of small (< 2 cm) umbilical hernias: guidelines and current trends from the Herniamed Registry

INTRODUCTION

Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2 cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2 cm) umbilical hernias over the past 10 years.

METHODS

Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented.

RESULTS

A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2 cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2 cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013.

CONCLUSIONS

A suture technique is still used to treat 75% of patients with small (< 2 cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.

Open Repair of Primary Versus Recurrent Male Unilateral Inguinal Hernias: Perioperative Complications and 1-Year Follow-up

Introduction

The recommendation in the European Hernia Society Guidelines for the treatment of recurrent inguinal hernias is to modify the technique in relation to the previous technique, and use a new plane of dissection for mesh implantation. However, the registry data show that even following previous open suture and mesh repair to treat a primary inguinal hernia, open suture and mesh repair can be used once again for a recurrent hernia. It is therefore important to know what the outcome of open repair of recurrent inguinal hernias is compared with open repair of primary inguinal hernias, while taking the previous operation into account.

Patients and methods

In the Herniamed Registry, a total of 17,594 patients with an open primary or recurrent unilateral inguinal hernia repair in men with a 1-year follow-up were prospectively documented between September 1, 2009 and August 31, 2013. Of these patients, 15,274 (86.8 %) had an open primary and 2320 (13.2 %) open recurrent repair. In the unadjusted and multivariable analyses, the dependent variables were intra- and postoperative complications, reoperations, recurrences, pain at rest, pain on exertion, and pain requiring treatment.

Results

Open recurrent repair compared with the open primary operation is a significant influence factor for higher intraoperative (p = 0.01) and postoperative (p = 0.05) complication rates, recurrence rate (p < 0.001), and pain rates (p < 0.001). With regard to repair of recurrent inguinal hernia, previous open mesh repair was associated with the least favorable outcome, and with the highest odds ratio, for all outcome criteria. Open recurrent repair following previous endoscopic operation presented the least risk for postoperative complications, complication-related reoperations, and re-recurrences. The pain rates identified on follow-up after open recurrent repair were lower following previous open suture operation compared with following open and endoscopic mesh repair.

Summary

A significantly less favorable perioperative and 1-year follow-up outcome must be expected for open repair of recurrent inguinal hernia in comparison with open primary inguinal hernia repair. After open recurrent repair, the most favorable perioperative complication and recurrence rates were identified following previous endoscopic repair, and the lowest pain rates following previous open suture repair. Open recurrent repair following previous open mesh operation was associated with the highest risks for perioperative complications, re-recurrences, and pain.

Female sex as independent risk factor for chronic pain following elective incisional hernia repair: registry-based, propensity score-matched comparison

Introduction

To date, little attention has been paid by surgical scientific studies to sex as a potential influence factor on the outcome. Therefore, there is a sex bias in the surgical literature. With an incidence of more than 20% after 3 years, incisional hernias are a common complication following abdominal surgical procedures. The proportion of women affected is around 50%. There are very few references in the literature to the influence of sex on the outcome of elective incisional hernia repair.

Materials and methods

In all, 22,895 patients with elective incisional hernia repair from the Herniamed Registry were included in the study. The patients had undergone elective incisional hernia repair in a laparoscopic IPOM, open sublay, open IPOM, open onlay or suture technique. 1-year follow-up was available for all patients. Propensity score matching was performed for the 11,480 female (50.1%) and 11,415 male (49.9%) patients, creating 8138 pairs (82.0%) within fixed surgical procedures.

Results

For pain on exertion (11.7% vs 18.3%; p < 0.001), pain at rest (7.53% vs 11.1%; p < 0.001), and pain requiring treatment (5.4% vs 9.1%; p < 0.001) highly significant disadvantages were identified for the female sex when comparing the different results within the matched pairs. That was also confirmed on comparing sex within the individual surgical procedures. No sex-specific differences were identified for the postoperative complications, complication-related reoperations or recurrences. Less favorable intraoperative complication results in the female sex were observed only for the onlay technique.

Conclusions

Female sex is an independent risk factor for chronic pain after elective incisional hernia repair.

Potential influencing factors on the outcome in incisional hernia repair: a registry-based multivariable analysis of 22,895 patients

INTRODUCTION

Due to the paucity of randomized controlled trials, meta-analyses of incisional hernia repair can hardly give any insights into the influence factors on the various outcome criteria. Therefore, a multivariable analysis of data from the Herniamed Registry was undertaken with the aim to define potential influencing factors for the outcome.

METHODS

Multivariable analysis of the data available for 22,895 patients with primary elective incisional hernia repair was performed to assess the confirmatory predefined potential influence factors and their association with the perioperative and 1-year follow-up outcomes. A model validation procedure was implemented using a bootstrap algorithm in order to account for the robustness of results.

RESULTS

Higher European Hernia Society (EHS) width classification, open procedure, female gender, and preoperative pain have a highly significant association with an unfavorable outcome in incisional hernia repair. Larger defect width and open operation have a highly significantly unfavorable relation to the postoperative surgical complications, general complications, and the complication-related reoperations, while female gender and preoperative pain have a highly significantly unfavorable association with the rates of pain at rest, pain on exertion, and chronic pain requiring treatment at 1-year follow-up. The recurrence rate is significantly unfavorably influenced by higher EHS width classification, higher BMI, and lateral EHS classification.

CONCLUSION

Higher EHS width classification, open procedure, female gender, higher BMI, and lateral EHS classification, as well as preoperative pain are the most important unfavorable influencing factors associated with a worse outcome in incisional hernia repair.

Development of a standardized curriculum concept for continuing training in hernia surgery: German Hernia School

INTRODUCTION

The increasingly more complex nature of hernia surgery means that training programs for young surgeons must now meet ever more stringent requirements. There is a growing demand for improved structuring and standardization of education and training in hernia surgery.

MATERIALS AND METHODS

In 2011, the concept of a Hernia School was developed in Germany and has been gradually implemented ever since. That concept comprises the following series of interrelated, tiered course elements: Hernie kompakt (Hernia compact), Hernie konkret (Hernia concrete), and Hernie complex (Hernia complex). All three course elements make provision for structured clinical training based on guest visits to approved hernia centers. The Hernia compact basic course imparts knowledge of anatomy working with fresh cadavers. Hernia surgery procedures can also be conducted using unfixed specimens. Knowledge of abdominal wall ultrasound diagnostics is also imparted and hernia surgery procedures simulated on pelvic trainers. In all three course elements, lectures are delivered by experts across the entire field of hernia surgery using evidence-based practices from the literature.

RESULTS

To date, eight Hernie kompakt (Hernia compact) courses have been conducted, in each case with up to 55 participants, and with a total of 390 participants. On evaluating the course, over 95% of participants expressed the view that the Hernia compact course content improved hernia surgery training. Following that positive feedback, the more advanced Hernie konkret (Hernia concrete) and Hernie complex (Hernia complex) course elements were introduced in 2016.

CONCLUSION

The experiences gained to date since the introduction of a Hernia School-a standardized curriculum concept for continuing training in hernia surgery-has been evaluated by participants as an improvement on hitherto hernia surgery training.

Analysis of 4,015 recurrent incisional hernia repairs from the Herniamed registry: risk factors and outcomes

INTRODUCTION

The proportion of recurrences in the total collective of all incisional hernias has been reported to be around 25%. In the European Hernia Society (EHS) classification, recurrent incisional hernias are assigned to a unique prognostic group and considered as complex abdominal wall hernias. Surgical repairs are characterized by dense adhesions, flawed anatomical planes caused by previous dissection or mesh use, and device-related complications. To date, only relatively small case series have been published focusing on outcomes following recurrent incisional hernia repair. This cohort study now analyzes the outcome of recurrent incisional hernia repair assessing potential risk factors based on data from the Herniamed registry. Special attention is paid to the technique used during the primary incisional hernia repair, since laparoscopic IPOM was recently deemed to cause more complications during subsequent repairs.

METHODS

In the multicenter Internet-based Herniamed registry, patients with recurrent incisional hernia repair between September 2009 and January 2018 were enrolled. In a confirmatory multivariable analysis, factors potentially associated with the outcome parameters (intraoperative, postoperative and general complications, complication-related reoperations, re-recurrences, pain at rest and on exertion, and chronic pain requiring treatment at one-year follow-up) were evaluated.

RESULTS

In total, 4015 patients from 712 participating hospitals were included. Postoperative complications and complication-related reoperations were significantly associated with larger recurrent hernia defect size, open recurrent incisional hernia repair and the use of larger meshes. General complications were more frequent in female sex patients and when larger meshes were used. Higher re-recurrence rate was observed with lateral defect localization, present risk factors, and time interval ≤ 1 year between primary and recurrent incisional hernia repair. Pain rates at 1-year follow-up were unfavorably related with pre-existing preoperative pain, female sex, lateral defect localization, larger mesh, presence of risk factors, and postoperative complications. As regards the primary incisional hernia repair technique, laparoscopic IPOM was found to show no effect versus open mesh techniques on the subsequent recurrence repair, despite a trend toward higher rates of complication-related reoperations.

CONCLUSION

The outcomes of recurrent incisional hernia repair were significantly associated with potential influencing factors, which are very similar to the factors seen in primary incisional hernia repair. The impact of the primary incisional hernia repair technique, namely laparoscopic IPOM versus open mesh techniques, on the outcome of recurrent incisional hernia repair seems less pronounced than anticipated.

A systematic review of outcome reporting in incisional hernia surgery

Background

The incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies.

Methods

Literature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included.

Results

In total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used.

Conclusions

This review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

Assessment of potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair: a registry-based multivariable analysis of 31,965 patients

INTRODUCTION

How best to treat a small (< 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors.

METHODS

The data of patients with primary elective umbilical hernia repair and defect size < 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up.

RESULTS

31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates.

CONCLUSION

Suture repair continues to be used for 78% of umbilical hernias with a defect < 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).

Abdominal incision defect following AAA-surgery (AIDA): 2-year results of prophylactic onlay-mesh augmentation in a multicentre, double-blind, randomised controlled trial

The reported incidence of incisional hernia following repair of abdominal aortic aneurysm (AAA) via midline laparotomy is up to 69%. This prospective, multicenter, double-blind, randomised controlled trial was conducted at eleven hospitals in Germany. Patients aged 18 years or older undergoing elective AAA-repair via midline incision were randomly assigned using a computer-generated randomisation sequence to one of three groups for fascial closure: with long-term absorbable suture (MonoPlus^®, group I), long-term absorbable suture and onlay mesh reinforcement (group II) or extra long-term absorbable suture (MonoMax^®, group III). The primary endpoint was the incidence of incisional hernia within 24 months of follow-up, analysed by intention to treat. Physicians conducting the postoperative visits and the patients were blinded. Between February 2011 and July 2013, 104 patients (69.8 ± 7.7 years) were randomised, 99 of them received a study intervention. The rate of incisional hernia within 24 months was not significantly reduced with onlay mesh augmentation compared to primary suture (p = 0.290). Furthermore, the rate of incisional hernia did not differ significantly between fascial closure with slow and extra long-term absorbable suture (p = 0.111). Serious adverse events related to study intervention occurred in five patients (5.1%) from treatment groups II and III. Wound healing disorders were more frequently seen after onlay mesh implantation on the day of discharge (p = 0.010) and three (p = 0.009) and six (p = 0.023) months postoperatively. The existing evidence on prophylactic mesh augmentation in patients undergoing AAA-repair via midline laparotomy probably needs critical review. As the implementation of new RCTs is considered difficult due to the increasing number of endovascular AAA treated, registry studies could help to collect and evaluate data in cases of open AAA-repair. Comparisons between prophylactic mesh implantation and the small bite technique are also required. Trial registration: ClinicalTrials.gov Identifier: NCT01353443. Funding Sources: Aesculap AG, Tuttlingen, Germany.

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.

[Ventral hernias part 1 : Operative treatment techniques]

Primary (umbilical, epigastric hernias) and secondary (incisional hernias) ventral hernias are among the most common surgical indications in general and visceral surgery. The defect width and defect localization have a considerable impact on treatment decision-making and outcomes. Therefore, preoperative computed tomography (CT) examination is increasingly recommended particularly for larger incisional hernias. Despite the good results reported in meta-analyses and registry analyses, in recent years there has been a marked trend away from the intraperitoneal onlay mesh (IPOM) technique as severe complications have repeatedly been reported. To continue to benefit from the advantages conferred by a minimally invasive access route with fewer wound complications, a myriad of new techniques with small incisions or endoscopic access have been developed. These involve mesh placement in the sublay/retromuscular/preperitoneal position. This provides a relatively differentiated tailored approach.

[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.

Mini- or less-open sublay (E/MILOS) operation vs open sublay and laparoscopic IPOM repair for the treatment of incisional hernias: a registry-based propensity score matched analysis of the 5-year results

BACKGROUND

Open sublay and laparoscopic IPOM repair have specific disadvantages and risks. In recent years, this evidence led to a paradigm shift and induced the development of new minimally invasive techniques of sublay mesh repair.

METHODS

Pioneering this trend, we developed the endoscopically assisted mini- or less-open sublay (MILOS) concept. The operation is performed trans-hernially via a small incision with light-holding laparoscopic instruments either under direct, or endoscopic visualization. After dissection of an extra-peritoneal space of at least 8 cm, port placement and CO2 insufflation, each MILOS operation can be continued endoscopically (EMILOS repair). All E/MILOS operations were prospectively documented in the Herniamed Registry with 1- and 5-year questionnaire follow-ups. Propensity score matching of incisional hernia operations comparing the results of the E/MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from all other institutions participating in the Herniamed Registry was performed. The results with perioperative complications and 1-year follow-up have been published previously.

RESULTS

This paper reports on the 5-year results. The 5-year follow-up rate was 87.5% (538 of 615 patients with E/MILOS incisional hernia operations). Comparing E/MILOS repair with laparoscopic IPOM and open sublay operation, propensity score matching analysis was possible with 448 and 520 pairs of operations, respectively. Compared with laparoscopic IPOM incisional hernia operation, the E/MILOS repair is associated with significantly fewer general complications (P = 0.004), recurrences (P < 0.001), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.016) and tends to result in fewer postoperative complications (P = 0.052), and less pain at rest (P = 0.053). Matched pair analysis with open sublay repair revealed significantly fewer general complications (P < 0.001), postoperative complications (P < 0.001), recurrences (P = 0.002), less pain at rest (P = 0.004), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.014). A limitation of this analysis is a relative low 5-year follow-up rate for laparoscopic IPOM and open sublay.

CONCLUSIONS

The E/MILOS technique allows minimally invasive trans-hernial repair of incisional hernias using large standard meshes with low morbidity and good long-term results. The technique combines the advantages of sub-lay repair and a mini- or less-invasive approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03133000.

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.

Technical aspects of inguino scrotal hernia surgery in developing countries

PURPOSE

Technical aspects of inguinoscrotal herniorrhaphy performed in low to middle income countries (LMICs) are described here to help surgeons who will operate on these challenging hernias in austere settings.

METHODS

Technical considerations related to operative repair were delineated with the consensus of 7 surgeons with extensive experience in inguinoscrotal hernia repair in LMICs. Important steps and illustrations were prepared accordingly. The anatomical and pathologic differences and technical implications of operating in limited resource settings are emphasized with suggestions to approach anticipated challenges. Pre-operative evaluation, anesthetic considerations, and technical guidelines are offered in context.

RESULTS

The authors have cumulatively performed over 1775 inguinoscrotal Lichtenstein operations in LMICs. While dedicated, reliable, long-term follow-up is unavailable from LMICs, one author reports outcomes with 5 year follow-up from the HerniaMed registry using the identical technique in similarly classed hernias. In 90 inguinoscrotal Lichtenstein repair patients (78.3% follow-up), there was one recurrence, low rates of chronic pain (2.2% at rest, 4.4% with activity), and low rates of reintervention (1.1%).

CONCLUSION

There is a difference between inguinal hernias found in LMICs and those seen in high-income countries with larger, chronic, and more technically challenging pathology. The consequences of intra-operative complications can be catastrophic in a LMIC. Technical measures are offered to improve outcomes, avoid and manage complications, and provide optimal care to this important population.

[Inguinal hernia operations-Always outpatient?]

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.