Systematic review of transversus abdominis release in complex abdominal wall reconstruction

Comparing the outcomes of external oblique and transversus abdominus release using the AHSQC database

PURPOSE

Myofascial release techniques at the time of complex hernia repair allow for tension-free closure of the midline fascia. Two common techniques are the open external oblique release (EOR) and the transversus abdominis release (TAR). Each technique has its reported advantages and disadvantages, but there have been few comparative studies. The purpose of this project was to compare the outcomes of these two myofascial release techniques.

METHODS

The Americas Hernia Society Quality Collaborative (AHSQC) database was queried and produced a data set on 24 May 2018. All patients undergoing open incision hernia repair with an open EOR or TAR were evaluated, and outcomes were compared including hernia recurrence, quality of life, and 30-day wound-related complications.

RESULTS

3610 patients met the inclusion criteria of undergoing open incisional hernia repair (501 undergoing EOR and 3109 undergoing TAR). Seventy surgeons from 50 institutions contributed EOR patients, and 124 surgeons from 89 institutions contributed TAR patients with no differences between the two groups in surgeons' affiliation. Comparing open EOR and TAR showed no significant differences in hernia recurrence, quality of life, or 30-day surgical site infection rate. EOR had a significantly higher rate of surgical site occurrences compared with TAR (p < 0.05); however, this did not result in an increase in surgical site occurrences requiring procedural interventions.

CONCLUSIONS

Equivalent outcomes were achieved using the EOR or TAR techniques in the open repair of incisional hernias. Both techniques offer consistently good outcomes and are important adjuncts in the repair of complex incisional hernias.

New techniques in ventral hernia surgery - an evolution of minimally-invasivehernia repairs

Incisional ventral hernia occurs after almost every fourth laparotomy. Still, both simple suturing of the hernia defect and open mesh repair, lead to a high incidence of infections and recurrences. In recent years, we have observed a further evolution of operational techniques used in order to reduce the number of complications. The search for effective repair methods is currently going in two directions: on the one hand, techniques to reduce tissue tension in the suture line are being developed and disseminated (including modifications to the so-called Ramirez technique); on the other hand, minimally invasive techniques are introduced that allow placement of large synthetic meshes without the need for extensive tissue dissection using open repair. In the first group of presented techniques, emphasis is put on basics and access in the following repair method: original Ramirez technique, modified Ramirez technique, anterior component separation with periumbilical perforator-sparing, endoscopic anterior component separation and transversus abdominis release. In the second part of the manuscript, attention is drawn to the following hernia repair techniques: eTEP, reversed TEP, MILOS/eMILOS, stapler repair, TAPP, TARUP, TESLA, SCOLA, REPA, LIRA, IPOM, IPOM-plus. When choosing the optimal technique for a given patient, the surgeon should first of all be guided by technical feasibility, availability of materials, their own experience, as well as the characteristics of the patient and overall burdens. Nevertheless, surgeons undertaking reconstruction of the abdominal wall in the case of hernias should know different surgical accesses and individual spaces of the abdominal integument, in which a synthetic material may be placed. However, it should be emphasized that poor ergonomics of novel techniques, complex anatomy and complicated dissection of space, as well as the need for laparoscopic suturing in a difficult arrangement of tissue layers and in a narrow space, without a full triangulation of instruments, make these operations a challenge even for a surgeon experienced in minimally invasive surgeries.

An Evaluation of Tension Measurements During Myofascial Release for Hernia Repair

Tension-free repairs have revolutionized the way we repair hernias. To help reduce undue tension when performing ventral hernia repair, multiple different techniques of myofascial releases have been described. The purpose of this project is to evaluate tension measurements for commonly performed myofascial releases in abdominal wall hernia repair. Patients undergoing myofascial release techniques for their ventral hernias were enrolled in a prospective Institutional Review Board-approved protocol to measure abdominal wall tension from June 1, 2011 to August 1, 2019. Abdominal wall tensions were measured using tensiometers before and after myofascial release techniques. Descriptive statistics were performed and data were analyzed. Thirty patients had tension measurements (5 anterior myofascial separation, 25 posterior myofascial separation with transversus abdominis release [TAR]). Average age was 60.1 years (range 29-81), 83% Caucasian, 53% female, and 42% recurrent hernias. The average hernia defect in patients undergoing anterior myofascial release was 117.3 cm2, and the average mesh size was 650 cm2. The reduction in tension after anterior release was 4.7 lbs (2.7 lbs vs 7.4 lbs). The average hernia defect in patients undergoing posterior myofascial release (TAR) was 183 cm2, and the average mesh size was 761.36 cm2. The reduction in tension after bilateral posterior rectus sheath incision was 2.55 lbs (5.01 lbs vs 7.56 lbs) with 0.66 lbs further reduction in tension after TAR (4.35 lbs vs 5.01). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair. Preliminary data show tension reductions associated with the different myofascial release techniques and, with further study, may be a useful intraoperative adjunct for decision making in hernia repair.

Hybrid robotic transversus abdominis release versus open: propensity-matched analysis of 30-day outcomes

PURPOSE

To examine the hospital length of stay (LOS) and 30 day outcomes of hybrid robotic transversus abdominis release (hrTAR) compared with open transversus abdominis release (oTAR).

METHODS

Patients receiving hrTAR were selected from the AHSQC database and propensity matched with a contemporary cohort of oTAR patients.

RESULTS

The cohort included 95 hrTAR and 285 oTAR patients. There was a significantly shorter median LOS in the hrTAR cohort (3 vs. 5 days, p < 0.001). The rate of surgical site occurrences in the hrTAR cohort was also lower than for oTAR (5% vs. 15%, p = 0.015). Readmission rates were not different between hrTAR and oTAR (6% vs. 8%, p = 0.65).

CONCLUSION

hrTAR demonstrates improved LOS compared to oTAR as well as fewer surgical site related occurrences. Further studies are needed to investigate the etiology behind the improved LOS and to confirm appropriate long-term outcomes from hybrid robotic TAR.

Non-coated versus coated mesh for retrorectus ventral hernia repair: a propensity score-matched analysis of the Americas Hernia Society Quality Collaborative (AHSQC)

PURPOSE

The outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space.

METHODS

Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI).

RESULTS

3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group.

CONCLUSION

Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.

Retrospective analysis of defect reconstruction after abdominal wall tumor resection in 30 patients

PURPOSE

It is difficult to manage the full-thickness defect that is created by radical resection of an abdominal wall tumor. This report aimed to review our institutional experience with immediate reconstruction using mesh reinforcement after abdominal wall tumor resection.

METHODS

We retrospectively examined patients who underwent abdominal wall tumor resection with immediate mesh-reinforced reconstruction between April 2014 and November 2018. The patients' records were reviewed to collect data regarding their demographic characteristics, surgical procedures, and complications.

RESULTS

We identified 30 eligible patients, including 5 who underwent simultaneous resection of affected intra-abdominal organs or tissues. The median size of the resulting abdominal wall defect was 60 cm² (interquartile range: 32-127.5 cm²) and the median mesh size was 150 cm² (interquartile range: 150-225 cm²). The median operative time was 85 min (interquartile range: 60-133.8 min), the mean hospital stay was 19.4 ± 9.0 days, and the mean follow-up period was 28.6 ± 16.0 months. The complications included seroma (n = 4), infection (n = 2), massive hematoma (n = 1), and abnormal sensation (n = 3). Tumor recurrence was observed in two patients, and three patients died because of cancer progression. No patient developed a ventral hernia or abdominal bulging.

CONCLUSION

Immediate mesh-reinforced reconstruction is feasible and effective for patients who require abdominal wall tumor resection.

An early experience with transversus abdominis release for complex ventral hernias: a retrospective review of 100 cases

BACKGROUND

Transversus abdominis release (TAR) is a relatively recent surgical technique for ventral hernia repair which allows placement of a large prosthesis in the retro-muscular plane with considerable myofascial medialization. A retrospective review of 100 cases who underwent TAR for complex ventral hernias was performed to evaluate the safety and efficacy of TAR in a series of large ventral hernias.

METHODS

Between March 2016 and May 2019, 100 consecutive patients who underwent open TAR were identified from our prospectively maintained database. A retrospective review was performed to analyze patient demographics, peri-operative events, adverse outcomes and recurrence.

RESULTS

12 primary and 88 incisional hernia cases underwent TAR with prosthetic mesh repair during the study period. Mean age was 52.5 years, mean BMI was 30.87 kgs/m², mean ASA class 1.95. In our series, 41% were diabetic, 11% had COPD. All patients underwent preoperative CT scans. The mean defect was 140.18 cm². Average mesh area was 1344 cm². Average blood loss was 245 mL. Defects were bridged in 19% cases despite bilateral component separation. Readmission rate at 1 month was 3%, for wound complications. We recorded 9 surgical site infections, 17 surgical site occurrences, 10 of which needed procedural interventions. We recorded no recurrences at a mean follow-up duration of 20.2 months.

CONCLUSIONS

Our early results with TAR are encouraging. We have demonstrated that the repair allows anatomical reconstruction with a large sublay mesh while inflicting minimal morbidity. TAR can be a valuable tool in complex ventral hernia repair.

Transversus abdominis release (TAR): what are the real indications and where is the limit?

PURPOSE

To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure.

METHODS

Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center.

RESULTS

Recommendations regarding patient selection, optimization and technique for TAR are presented.

CONCLUSIONS

While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.

Preoperative Ultrasound-Guided Botulinum Toxin A Injection Facilitates Closure of a Complex Abdominal Wall Hernia: A Case Report

Complex abdominal wall hernia repairs can have high failure rates. Many surgical techniques have been proposed with variable success. We report our experience with a new collaborative protocol between general surgery and regional anesthesiology and acute pain medicine services to provide preoperative botulinum toxin A injections to a patient with a large complex ventral hernia to facilitate primary closure. Toxin was administered into the 3 abdominal wall muscle layers under ultrasound guidance at multiple sites 2 weeks before surgery. The resulting flaccid paralysis of the abdominal musculature facilitated a successful primary surgical closure with no postoperative complications.