Totally endoscopic surgery on diastasis recti associated with midline hernias. The advantages of a minimally invasive approach. Prospective cohort study

Endoscopic enhanced-view totally extraperitoneal retromuscular approach for ventral hernia repair

BACKGROUND

Primary or incisional ventral hernia repair is one of the most common surgical procedures, addressed to general surgeons. The enhanced view-totally extraperitoneal technique (eTEP) was first described by Deas for inguinal hernias, but lately it has been applied to ventral hernias by Belyansky et al. So far, results are promising and data about the procedure are rising.

METHODS

Retrospective comparative analysis of 27 recruited eTEP procedures and 27 IPOM operations for the period between April 2017 and June 2018 at the department of Endoscopic surgery of Military Medical Academy, Sofia. Baseline characteristics, operative records and perioperative data are provided and compared for both groups.

RESULTS

Fifty-four patients were included. There were no differences between age, sex, BMI, primary or incisional hernias, co-morbidity, active smoking, EHS-classification and immunosuppression through the patients in different groups. Mean defect area-eTEP is 71 cm² with no statistical difference, compared to IPOM-76 cm². Operative time in eTEP is significantly longer with mean time of 186 min and 90 min in IPOM patients. Mean length of stay did not differ between the groups, with 2.9 days after eTEP and 3.4 after IPOM. Median pain score from the intraoperative (the day of surgery) to the seventh postoperative day is lower in the eTEP group. No surgical site infections and/or mesh infections were present. There was one readmission in the IPOM group with ASBO, and it was managed conservatively. There were no reinterventions and perioperative mortality in the sample.

CONCLUSION

We found out that the eTEP/eRS approach is feasible and safe. Our study shows comparable results of eTEP/eRS to the IPOM procedure with reduced video analogue scale pain score to the 7th postoperative day and increased operative time. The study contributes to the upcoming evidence in the field of new minimally invasive techniques for ventral hernia repair.

Endo-laparoscopic reconstruction of the abdominal wall midline with linear stapler, the THT technique. Early results of the first case series

Background

Midline primary hernias represent one of the most frequent abdominal wall defects in the adult population and in almost half of the cases they are associated with a rectus abdominis diastasis (RAD). Despite the high incidence of these defects there is currently no consensus in the literature on what is the preferred surgical technique for treatment. In this paper we present the first case series treated with an innovative technique that aims to repair the defects of the midline and RAD, while combining the advantages of the sublay Rives-Stoppa technique with those of the minimally-invasive surgery.

Methods

Between January 2018 and May 2018, 14 patients underwent endo-laparoscopic reconstruction of the midline. The surgery was performed under general anaesthesia through a 4 cm periumbilical incision with single port technique. The rectus abdominis sheaths were joined together and sutured lengthwise using a linear stapler. A tailor-made synthetic prosthesis was positioned in the retromuscular space.

Results

All cases had RAD with a mean width of 5.3 cm in the supraumbilical space. None of the surgeries needed laparotomic conversion. The average duration of the surgery was 80 min. The hospitalization was in all cases one day. The average follow-up period was 6 months. Neither recurrences, nor major or minor complications have been reported to date.

Conclusion

Our THT is a feasible technique, easily reproducible, and effective in the repair of primary defects of the midline and RAD, which greatly reduces the operating times and hospitalization allowing a quick return to active life.

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The THT procedure is a surgical technique for repair of the abdominal wall midline hernias and rectus abdominis diastasis.

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The THT procedure combines the advantages of endoscopic single port surgery with those of a retromuscular prosthetic reconstruction.

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The THT procedure strongly reduces costs and operative times if compared to lap/robotic surgery while allows to avoid the complication risks related to a large laparotomy.

SUBCUTANEOUS ONLAY LAPAROSCOPIC APPROACH (SCOLA) FOR VENTRAL HERNIA AND RECTUS ABDOMINIS DIASTASIS REPAIR: TECHNICAL DESCRIPTION AND INITIAL RESULTS

Background:

Diastasis of the rectus abdominis muscles (DMRA) is frequent and may be associated with abdominal wall hernias. For patients with redudant skin, dermolipectomy and plication of the diastasis is the most commonly used procedure. However, there is a significant group of patients who do not require skin resection or do not want large incisions.

Aim:

To describe a “new” technique (subcutaneous onlay laparoscopic approach - SCOLA) for the correction of ventral hernias combined with the DMRA plication and to report the initial results of a case series.

Method:

SCOLA was applied in 48 patients to correct ventral hernia concomitant to plication of DMRA by pre-aponeurotic endoscopic technique.

Results:

The mean operative time was 93.5 min. There were no intra-operative complications and no conversion. Seroma was the most frequent complication (n=13, 27%). Only one (2%) had surgical wound infection. After a median follow-up of eight months (2-19), only one (2%) patient presented recurrence of DMRA and one (2%) subcutaneous tissue retraction/fibrosis. Forty-five (93.7%) patients reported being satisfied with outcome.

Conclusion:

The SCOLA technique is a safe, reproducible and effective alternative for patients with abdominal wall hernia associated with DMRA.

Management Strategies for Diastasis Recti

Diastasis recti is a relatively common condition in which there is a midline abdominal bulge that can affect a variety of individuals. The etiology and diagnosis is well understood and optimal management depends on the degree of severity. Patients at high risk for diastasis recti include multiparous women, obese patients, and those with multiple previous operations. Diagnosis includes clinical examination and assessment of symptoms. Physical characteristics include a midline abdominal bulge without a fascial defect. Classification systems are based on the degree of separation between the paired midline rectus and myofascial deformity. Optimal management varies and includes simple plication of the midline defect, extensive plication of the anterior abdominal wall, and sometimes the use of resorbable or nonresorbable mesh.

Diastasis of rectus abdominis muscles in low back pain patients

BACKGROUND

Abdominal muscles are important spinal stabilizers and its poor coordination, as seen in diastasis of rectus abdominis (DRA), may contribute to chronic low back pain (LBP). However, this has not yet been studied directly.

OBJECTIVES

To conduct a pilot study to examine the association between DRA and LBP.

METHODS

Using a digital caliper, standard clinical DRA measurement was performed in 55 participants with and 54 without chronic LBP.

RESULTS

Participants were on average 55 years old, 69 (63%) were women. Among the 16 participants with DRA, 11 (69%) had chronic LBP; among the 93 participants without DRA, 44 (47%) had LBP. Among men, 7 of 9 (77%) with DRA had LBP and 14 of 31 (45%) without DRA had LBP. Among women, 4 of 7 (57%) with DRA had LBP and 30 of 62 (48%) without DRA had LBP. BMI was the strongest correlate of DRA and may explain the relation between DRA and chronic LBP.

CONCLUSIONS

DRA and LBP may be interrelated, especially among men. This may be a function of greater BMI in individuals with chronic LBP. Understanding the association between DRA, LBP, and BMI may have important implications for treatment of LBP and for intervention.

Diastasis recti associated with midline hernias: Totally subcutaneous video-endoscopic repair

A 63-year-old man with a history of a conventional cholecystectomy was referred to our department for an incisional subcostal hernia and chronic back pain. Physical examination also showed an umbilical hernia and diastasis recti measuring 6 cm that was confirmed with a computed tomography scan. Subcutaneous video-endoscopic repair was done repairing all defects simultaneously.

The general surgeon's perspective of rectus diastasis. A systematic review of treatment options

BACKGROUND

Diastasis of the rectus abdominis muscles (DRAM) is characterised by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This causes the midline to "bulge" when intra-abdominal pressure is increased. Plastic surgery treatment for DRAM has been thoroughly evaluated, though general surgical treatments and the efficacy of physiotherapy remain elusive. The aim of this systematic literature review is to evaluate both general surgical and physiotherapeutic treatment options for restoring DRAM in terms of postoperative complications, patient satisfaction, and recurrence rates.

METHOD

MEDLINE^®, Embase, PubMed, PubMed Central^®, The cochrane central registry of controlled trials (CENTRAL), Google Scholar, and the Physiotherapy Evidence Database (PEDro) were searched using the following terms: 'rectus diastasis', 'diastasis recti', 'midline', and 'abdominal wall'. All clinical studies concerning general surgical or physiotherapeutic treatment of DRAM were eligible for inclusion.

RESULT

Twenty articles describing 1.691 patients (1.591 surgery/100 physiotherapy) were included. Surgical interventions were classified as plication techniques (313 patients; 254 open/59 laparoscopic), modified hernia repair techniques (68 patients, all open), and combined hernia & DRAM techniques (1.210 patients; 1.149 open/40 hybrid). The overall methodological quality was low. Plication techniques with interrupted sutures and mesh reinforcement were applied most frequently for DRAM repair. Open repairs were performed in 85% of patients. There was no difference in postoperative complications or recurrence rate after laparoscopic or open procedures, or between plication and modified hernia repair techniques. Physiotherapy programmes were unable to reduce IRD in a relaxed state. Though reduction of IRD during muscle contraction was described.

CONCLUSION

Both plication-based methods and hernia repair methods are used for DRAM repair. Based on the current literature, no clear distinction in recurrence rate, postoperative complications, or patient reported outcomes can be made. Complete resolution of DRAM, measured in a relaxed state, following a physiotherapy training programme is not described in current literature. Physiotherapy can achieve a limited reduction in IRD during muscle contraction, though the impact of this finding on patient satisfaction, cosmesis, or function outcome is unclear.

Endoscopic-assisted linea alba reconstruction: New technique for treatment of symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis

Background

Patients with symptomatic umbilical, trocar, and/or epigastric hernias and concomitant rectus abdominis diastasis represent a growing clinical problem. The optimal management of this complex hernia situation is the subject of debate in the literature. This paper reports the early results of an innovative surgical technique aimed at managing this hernia situation.

Methods

Endoscopic-assisted linea alba reconstruction (ELAR) with mesh augmentation is a surgical technique long known in the literature for its good outcome for incisional hernia repair (myofascial release, overlapping herniorrhaphy, Gibson’s operation, shoelace repair, anterior rectus sheath repair, dynamic patch plasty) via a small access route. The early results for 140 patients are presented here.

Results

Two patients (1.4%) developed postoperative complications requiring redo surgery. These were two cases of diffuse secondary bleeding without an identifiable bleeding source, in one patient with liver cirrhosis and portal hypertension and in another patient receiving treatment with platelet aggregation inhibitors. All other complications were successively managed with conservative treatment. After 1 year, two of 30 patients reported occasional pain, including pain at rest in one patient.

Conclusion

The ELAR technique with mesh augmentation is an innovative, minimally invasive surgical procedure for treatment of patients with a complex abdominal wall hernia comprising symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis.

Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: A randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures

BACKGROUND

The primary aim of this prospective, randomized, clinical, 2-armed trial was to evaluate the risk for recurrence using 2 different operative techniques for repair of abdominal rectus diastasis. Secondary aims were comparison of pain, abdominal muscle strength, and quality of life and to compare those outcomes to a control group receiving physical training only.

METHODS

Eighty-six patients were enrolled. Twenty-nine patients were allocated to retromuscular polypropylene mesh and 27 to double-row plication with Quill technology. Thirty-two patients participated in a 3-month training program. Diastasis was evaluated with computed tomography scan and clinically. Pain was assessed using the ventral hernia pain questionnaire, a quality-of-life survey, SF-36, and abdominal muscle strength using the Biodex System-4.

RESULTS

One early recurrence occurred in the Quill group, 2 encapsulated seromas in the mesh group, and 3 in the suture group. Significant improvements in perceived pain, the ventral hernia pain questionnaire, and quality of life appeared at the 1-year follow-up with no difference between the 2 operative groups. Significant muscular improvement was obtained in all groups (Biodex System-4). Patient perceived gain in muscle strength assessed with a visual analog scale improved similarly in both operative groups. This improvement was significantly greater than that seen in the training group. Patients in the training group still experienced bodily pain at follow-up.

CONCLUSION

There was no difference between the Quill technique and retromuscular mesh in the effect on abdominal wall stability, with a similar complication rate 1 year after operation. An operation improves functional ability and quality of life. Training strengthens the abdominal muscles, but patients still experience discomfort and pain.

Endoscopic-Assisted Linea Alba Reconstruction plus Mesh Augmentation for Treatment of Umbilical and/or Epigastric Hernias and Rectus Abdominis Diastasis - Early Results

INTRODUCTION

Symptomatic umbilical and/or epigastric hernias are often seen concomitantly with rectus abdominis diastasis (RAD), and suture repair of such defects has a high recurrence rate. In the literature, there are reports of both endoscopic and open techniques for repair of symptomatic umbilical and/or epigastric hernias in association with RAD. This paper now reports on the early results of a hybrid technique used for reconstruction of the linea alba and mesh augmentation [endoscopic-assisted linea alba reconstruction plus mesh augmentation (ELAR plus)].

MATERIALS AND METHODS

Between 15 June 2015 and 31 January 2016, 40 patients with symptomatic umbilical and/or epigastric hernia and concomitant RAD underwent reconstruction of the linea alba using a hybrid technique involving a small umbilical incision and the use of video-endoscopic equipment. The patients comprised 29 men and 11 women with a mean age of 53.6 years and mean BMI of 32.6. The mean operating time was 120 min. The mesh had a mean longitudinal extension of 18.6 cm and transverse extension of 9.1 cm.

RESULTS

Thirty-day follow-up results are available for all patients. Thirty-seven out of 40 patients (92.5%) experienced no postoperative complication. Two cases of discrete impaired umbilical wound healing and one seroma were successfully managed with conservative treatment. On 30-day follow-up, 3 out of 40 patients (7.5%) complained of intermittent pain on exertion, and 2 out of 40 patients (5%) still took painkillers when required.

CONCLUSION

ELAR plus is a novel minimally invasive procedure for repair of symptomatic umbilical and/or epigastric hernias with concomitant RAD. Reconstruction of the linea alba via a minimally invasive access route is able to restore the normal anatomy of the abdominal wall.

Validity of Inter-rectus Distance Measurement in Postpartum Women Using Extended Field-of-View Ultrasound Imaging Techniques

STUDY DESIGN

Reliability and validity study.

OBJECTIVES

To investigate the criterion-related validity and reliability of inter-rectus distance (IRD) measurement using extended field-of-view (FOV) techniques during ultrasound imaging (USI) in parous women.

BACKGROUND

Ultrasound imaging is the gold standard for noninvasive IRD measurement in parous women when investigating diastasis recti; however, its use is limited when IRD is large. Extended FOV techniques (panoramic USI or using acoustic standoff pads) allow complete visualization of the linea alba when the IRD is large and conventional imaging is not sufficient; however, the validity of using these techniques has never been investigated.

METHODS

Two-dimensional ultrasound images were acquired at the superior umbilical border from 21 women using conventional USI, panoramic USI, and a standoff pad. Five images were captured using each method. Inter-rectus distance was measured offline. Criterion-related validity was investigated using repeated-measures analyses of variance to test for bias, and linear regression models, Pearson correlation coefficients (r), and intraclass correlation coefficients (ICCs) to assess agreement. Standard error of the measurement for each extended FOV technique was calculated. The between-trial reliability of each technique was determined using ICCs.

RESULTS

Inter-rectus distance from images acquired using extended FOV techniques did not differ from values acquired using conventional USI (P = .441). Images acquired using extended FOV techniques were highly correlated with those acquired using conventional imaging (r>0.95, P<.0001). The standard error of the measurement of each extended FOV technique was 0.17 to 0.18 cm. The between-trial reliability of all techniques was excellent (ICC(3,1)>0.90).

CONCLUSION

Panoramic USI and acoustic standoff pads are valid methods of increasing FOV to measure IRD. In this study, USI measurements were limited to IRDs of less than or equal to 3 finger widths, based on palpation.

Ultrasound Imaging in Postpartum Women With Diastasis Recti: Intrarater Between-Session Reliability

STUDY DESIGN

Clinimetrics.

OBJECTIVES

To investigate the intrarater between-session reliability of inter-rectus distance (IRD) measurement using ultrasound imaging in postpartum women with diastasis recti.

BACKGROUND

Diastasis recti, a separation of the rectus abdominis muscles at the linea alba, occurs as a result of pregnancy and is characterized by increased IRD. The measurement of IRD in this population is of interest to determine changes in diastasis recti severity over time, or in response to treatment. Ultrasound imaging has been proposed as a useful tool to measure IRD in women with diastasis recti; however, the consistency of IRD measurement in this population using ultrasound imaging has, to our knowledge, never been investigated.

METHODS

Ultrasound imaging was used to measure IRD in 20 women with diastasis recti on 2 different occasions. On each testing occasion, images were acquired at 4 locations along the linea alba while participants remained relaxed and while they performed a head lift to activate the rectus abdominis muscles. Reliability statistics included intraclass correlation coefficients, Bland-Altman analyses, minimum clinically important difference, and standard error of the measurement.

RESULTS

Between-session reliability of IRD measurement was high, particularly when measuring IRD at or above the umbilicus, as indicated by intraclass correlation coefficients greater than 0.90 and low standard error of the measurement and minimum clinically important difference values (below 0.17 cm and 0.46 cm, respectively). Reliability coefficients were poorer when measuring IRD below the umbilicus.

CONCLUSION

When performed by an experienced investigator, ultrasound imaging is a reliable tool by which to measure IRD in postpartum women who have diastasis recti.