Meta-analysis of closure of the fascial defect during laparoscopic incisional and ventral hernia repair

Standardization of laparoscopic intraperitoneal onlay mesh repair for incisional hernia: Impact on clinical outcome and quality-of-life (LIPOM trial, NCT 02089958)

Purpose

Current available outcome data following laparoscopic intraperitoneal onlay mesh repair (IPOM) for incisional hernia (IH) are comparable to a limited extent only because of a huge number of variability particulary in surgical technique and use of medical devices. In this prospective observational multicenter cohort study we evaluate the impact of a consensus driven standard protocol for IPOM, that is mesh fixation with absorbable tacks in double crown technique enforced by additional non-absorbable transfascial sutures at the edges of the mesh along with the use of Physiomesh™, on clinical and patient reported outcome measures.

Methods

A total of 102 consecutive patients were screened for eligibility between September 2013 and October 2014. 85 patients (IH: EHS W1: n = 39, W2: n = 46) were included into the study. Clinical examination and PROM for pain and quality of life measure (Carolina Comfort Scale, CCS) were performed at baseline, during hospital stay and at 6 weeks, 6 months and 1 year follow-up.

Results

The follow-up rate was 87,1 % for the primary endpoint. The Kaplan-Meier estimate for freedom-of-recurrence at 1 year was 95.9 % (95 %-CI: 87.9-98.7 %), the cumulative recurrence rate at 1 year was 4.1 % (95 %-CI: 0.9-11.7 %). There was no intraoperative complication. One seroma (type I; 1/84 (1,2 %), 95 %-CI: 0-7.1 %) was diagnosed during hospital stay. 12 seroma (n = 12/74 (16,2 %), 95 %-CI: 9.4-26.4 %; n = 10 type II and n = 2 type IV) were diagnosed during follow-up requiring surgical intervention in 1 patient (1,4 %, Clavien Dindo grade IIIb). Subcutaneous hematoma were found during follow-up in 8 patients (8/75 (10.7 %); 95 %-CI: 5.3-19.9) with need for surgical intervention in 2 patients (2,7 %, Clavien Dindo grade IIIb). There were 3 superficial surgical site infections (3/74 (4,1 %); 95 %-CI: 0.9-11.7 %, Clavien-Dindo grade I) without need for reoperation. Patient reported pain as measured by numeric rating scale at baseline was 1.36 ± 1.53 and 0.35 ± 1.04 at 1 year follow-up. CCS total scores indicated a good outcome with a decrease to 2.80 ± 6.47 (Min: 0, Q1: 0, Median: 0; Q3: 3.0; Max: 38.0) at 1 year follow-up. Subscore sensation of mesh decreased from 4.01 ± 6.76 (min: 0, Q1: 0, Median: 0; Q3: 5.0; Max: 28.0) at 6 weeks to 1.67 ± 3.99 (Min: 0, Q1: 0, Median: 0; Q3: 1.0; Max: 21.0) after 6 months and 0.90 ± 2.69 (Min: 0, Q1: 0, Median: 0; Q3: 0; Max: 14.0) after 1 year follow-up. Subscores pain and movement limitation both decreased during follow-up and were significantly reduced at 1 year compared to preoperative assessment (p < 0.001).

Conclusions

This study showed favourable clinical and patient reported outcomes and a low rate of recurrences at 1 year follow-up after IPOM for elective IH applying a standardized surgical technique including the use of Physiomesh™. In view of the data leading to the market withdrawal of the Physiomesh™, one might conclude, that the described standard may have contributed to a compensation of the suspected delay in tissue integration of the Physiomesh™ resulting in a more proper mesh fixation compared to absorbable tack fixation with/without absorbable TFS. This may lead to the general appraisal, that the fixation technique has to be adapted to the individual characteristics of type of mesh and fixation devices and the planned anatomic landing zone of the mesh.

Percutaneous inguinal canal semi-closure during laparoscopic repair for large indirect inguinal hernia

BACKGROUND

Factors such as a large lateral hernia and insufficient prosthetic overlap have been associated with hernia recurrence after laparoscopic transabdominal preperitoneal (TAPP) repair. The effectiveness of defect closure in reducing recurrence during laparoscopic hernia repair has been previously reported. We developed a novel technique called percutaneous inguinal canal semi-closure (PICS) to reinforce laparoscopic mesh repair.

PURPOSE

To assess whether this technique is both safe and practical in a clinical setting, focusing on postoperative factors such as recurrence, complications, and postoperative pain.

METHODS

A retrospective analysis of consecutive patients undergoing TAPP for L3 hernia repair.

RESULTS

In total, 58 patients who underwent TAPP for L3 inguinal hernias were included, 27 of whom (46.6%) underwent TAPP with PICS, while 31 (53.4%) underwent standard TAPP without PICS. No recurrences were observed in the PICS group, compared to two recurrences in the control group, although this difference did not reach statistical significance. The incidence of postoperative complications was comparable between groups (48.1% vs. 45.2%, respectively). The median procedure time of PICS was 7.3 min. Patients in the PICS group reported higher pain scores than the control group for up to 21 days postoperatively, but no chronic pain was observed in either group.

CONCLUSION

The modified laparoscopic technique involving PICS for large indirect inguinal hernias appears safe and feasible.

A Real-World Experience of the Short-Term Clinical Outcomes of Laparoscopic and Robotic-Assisted Ventral Hernia Repairs

BACKGROUND

This study aims to provide the first comparative real-world evidence of laparoscopic and robotic-assisted ventral hernia repairs performed in India, regardless of defect size or technique used.

METHODS

The primary objective was to compare postoperative pain, analgesic use, and quality of life (QOL) between the two groups. Additionally, data on length of hospital stay, operating time, incidence of intra- and postoperative complications, re-admission rates, and use of tacks were collected and analyzed.

RESULTS

The study included 290 cases: 111 (38.28%) in the robotic group and 179 (61.72%) in the laparoscopic group. Incisional hernias were more common in the robotic group (65 patients, 58.56%), while primary ventral hernias were more prevalent in the laparoscopic group (113 patients, 63.13%). The most common robotic repair approach was extended totally extraperitoneal Rives-Stoppa (eTEP-RS) with or without transversus abdominis release (TAR), performed in 75 (67.56%) cases. In the laparoscopic group, intraperitoneal onlay mesh (IPOM) plus was the most frequently performed procedure, used in 115 (64.25%) cases. The robotic group reported significantly lower pain levels after 6 hours, 24 hours, and 14 days following surgery. The number and duration of analgesic use were significantly reduced in the robotic group. Additionally, the robotic group had significantly better health perception scores. Compared to the laparoscopic group, the robotic group experienced significantly fewer postoperative complications (2 vs. 16; p = 0.013). Notably, the robotic group did not use tacks for mesh fixation, while tacks were employed in roughly 116 (64.8%) of the laparoscopic cases.

CONCLUSION

In real-world Indian settings, this study demonstrates the feasibility of robotic-assisted ventral hernia repairs, regardless of defect size or technique used.

Postoperative outcomes and wound events in incisional hernia repair using hybrid mesh: results from a prospective multicenter italian study

PURPOSE

The complexity of managing ventral hernias leads surgeons to explore different optimal techniques and mesh selection. Hybrid meshes, combining absorbable and permanent components, aim to balance long-term durability and infection risk. This study evaluated the extended-term outcomes of GORE® SYNECOR intraperitoneal (IP) biomaterial for incisional hernia repair through minimally invasive laparoscopic techniques.

METHODS

Conducted across eight Italian surgery centers from January 2020 to September 2022, this multicenter analysis prospectively assessed the outcomes of patients undergoing laparoscopic repair of incisional hernias using GORE® SYNECOR. Outcomes included postoperative wound events, pain, recurrence, and mesh bulging.

RESULTS

A total of 371 patients participated in the study. No serious adverse events or significant mesh-related complications were observed. Surgical site occurrences (SSO) were recorded in a proportion of cases, and hernia sac volume was identified as the only independent risk factor (p < 0.0001). At three months post-surgery, pain levels and impacts on daily activities were minimal. At 24 months, recurrence and mesh bulging were associated only with patients with hernia sac sizes larger than 450 cm3.

CONCLUSION

Laparoscopic incisional hernia repair using GORE® SYNECOR hybrid mesh demonstrated satisfactory safety and efficacy regarding wound-related events and recurrence. Minor complications were more closely related to hernia sac size rather than the surgical approach, suggesting that the laparoscopic technique may optimize outcomes, particularly in elderly, smokers, and overweight patients.

CLINICALTRIALS

NCT06166069.

Robotic sugarbaker parastomal hernia repair: updated series and outcomes

PURPOSE

To present updated outcomes after previously describing a novel technique for the robotic repair of parastomal hernias.

METHODS

Patients who underwent parastomal hernia repair with a robotic Sugarbaker technique at a tertiary hernia center were identified from an institutional database. The approach involves mesh placement in the intraperitoneal or preperitoneal position after closure of the fascial defect. Baseline demographics, intra-operative variables, and post-operative outcomes were evaluated.

RESULTS

Twenty-six patients were identified who underwent robotic Sugarbaker parastomal hernia repair with mesh. Median age was 61.5 (IQR 58.0-67.0) years, 17 (65%) were male, and median BMI was 29.5 (IQR 25.7-32.6) kg/m2. Stoma types included 11 (42%) colostomies, 8 (31%) ileostomies, and 7 (27%) urostomies. All but one case was elective (96%) and 2 (8%) were recurrent. Median operative time was 182.5 (IQR 149-209) min. Biologic mesh was used in 5 (19%) and synthetic mesh in 21 (81%) cases. Concurrent hernia repair was performed in 11 (42%) cases. Two (8%) patients were converted from a robotic to open procedure. Median length of stay was 4 (IQR 3-6) days. A total of 3 (11.5%) patients underwent reoperation related to obstruction at the stoma site. There were no additional 30-day readmissions, seromas requiring intervention, or wound complications. There were 4 (15%) total recurrences during a median follow up of 29.1 (IQR 10.0-55.8) months.

CONCLUSIONS

Robotic Sugarbaker parastomal hernia repair is an effective technique for minimally invasive repair of parastomal hernias. Care should be taken to prevent obstruction of the stoma related to fascial and peritoneal flap reconstruction or mesh placement, which is a significant risk of this technique.

Hybrid intraperitoneal onlay mesh repair for incisional hernias: a systematic review and meta-analysis

INTRODUCTION

Laparoscopic IPOM is technically challenging, especially regarding fascial closure. Hybrid repair has been proposed as a simpler approach. We aimed to compare hybrid and laparoscopic intraperitoneal onlay mesh repair (IPOM) in patients undergoing ventral hernia repair (VHR).

METHODS

We performed a systematic review of Cochrane, Scopus, and MEDLINE databases to identify studies comparing hybrid versus laparoscopic IPOM VHR reporting the outcomes of recurrence, mortality, seroma, postoperative complications, reoperation, surgical site infection, and operative time. Statistical analysis was performed using RStudio 4.1.2 using a random-effects model.

RESULTS

We screened 2,896 articles and fully reviewed 22 of them. A total of five studies, encompassing 664 patients were included. Among them, 337 (50.8%) underwent laparoscopic IPOM. All patients had incisional hernias, with a mean diameter varying from 3 to 12.7 cm, 60% were women, with a mean BMI varying from 29.5 to 38. The hybrid approach had a lower rate of seroma when compared to the laparoscopic (OR 0.22; 95% CI 0.05 to 0.92; p = 0.038; I²=78%). We found no difference in recurrence, mortality, postoperative complications, reoperation, surgical site infection, and operative time between groups.

CONCLUSION

Hybrid IPOM is a safe and effective method for incisional hernia repair. Moreover, it facilitates fascial defect closure and decreases postoperative seromas.

The current role of barbed sutures in fascial closure of ventral hernia repair: a multicenter study using the abdominal core health quality collaborative database

BACKGROUND

Barbed sutures (BS) have been increasingly used in the last two decades across surgical disciplines but little is known about how widespread their adoption has been in ventral hernia repair (VHR). The aim of this study was to document the use of barbed sutures in VHR in a multicenter database with associated clinical and patient-reported outcomes.

METHOD

Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent VHR with fascial closure from 2020 to 2022. A univariate analysis compared patients with BS against non-barbed sutures (NBS) across the preoperative, intraoperative, and postoperative timeframes including patient-reported outcomes concerning quality of life and pain scores.

RESULTS

A total of 4054 patients that underwent ventral hernia repair with BS were compared with 6473 patients with non-barbed sutures (NBS). Overall, BS were used in 86.2% of minimally invasive ventral hernia repairs and about 92.2% of robotic surgery compared to only 9.6% of open procedures. Notable differences existed in patient selection, including a higher BMI (32 vs 30.5; p < 0.001), more incisional hernias (63.3% vs 51.1%; p < 0.001), wider hernias (4 cm vs 3 cm; p < 0.001), and higher ASA score (p < 0.001) in patients with BS. Outcomes in patients with BS included a shorter length of stay (mean days; 1.4 vs 2.4; p < 0.001), less SSI (1.5% vs 3.6%; p < 0.001), while having similar SSO (7.6% vs 7.3%; p = 0.657), readmission (3.0 vs 3.2; p = 0.691), and reoperation (1.5% vs 1.45%; p = 0.855), at a longer operative time (p < 0.001). Hernia-specific questionnaires for quality of life (HerQLes) and pain in patients with BS had a worse preoperative score that was later matched and favorable compared to NBS (p = 0.048). PRO concerning hernia recurrence suggest around 10% at two years of follow-up (p = 0.532).

CONCLUSION

Use of barbed sutures in VHR is widespread and highly related to MIS. Outcomes from this multicenter database cannot be reported as superior but suggest that barbed sutures do not have a negative impact on outcomes.

The Evolving Applications of Laparoscopic Intracorporeal Rectus Aponeuroplasty (LIRA) in Ventral Hernia Repair-A Systematic Review

Purpose

Laparoscopic intracorporeal rectus aponeuroplasty (LIRA), emerged as a method that combines benefits from minimally invasive and abdominal wall reconstruction with defect closure, restoring the midline without tension by folding the posterior aponeurosis of both abdominal rectus muscles and using intraperitoneal mesh repair. We aimed to perform a systematic review of the existing evidence on LIRA results and potential applications.

Source

A thorough search of Cochrane Central, Scopus, SciELO, LILACS, and PubMed/MEDLINE, focusing on studies that explored LIRA's possible applications and results was performed. Key outcomes evaluated included recurrence, seroma, hematoma, surgical site infection (SSI), and length of hospital stay. We included both analytic data and descriptive studies.

Principal Findings

Out of 128 screened studies, three met the inclusion criteria and comprised 113 patients, of which 69 (61.1%) were operated using LIRA. Three studies comprised two case series of conventional and robotic LIRA repair, and one comparative study of LIRA versus intraperitoneal underlay mesh repair (IPUM plus). No surgical site infections were reported. Seroma rates ranged between 11.1% and 50%, while no bleeding or hematoma was noted. There were no patients presenting recurrence in a median follow-up ranging from 12 to 15 months, despite the comparative study reporting a 4.4% rate of bulging without clinical recurrence. The mean length of hospital stay ranged from 12 to 36 h. LIRA presented no differences in postoperative complications compared to the IPUM plus technique.

Conclusion

LIRA is linked to low recurrence and postoperative complications. It is a novel approach with potential applications in various types of primary and incisional ventral hernias.

To close, not to close, or to act bigger? Managing the defect of large direct inguinal hernia to reduce the risk of recurrence during laparoscopic TAPP repair: a retrospective cohort study

Hernia recurrence is a common complication after inguinal hernia repair. Recent studies suggest that laparoscopic mesh repair with closure of direct hernia defects can reduce recurrence rates. Our study examines the effectiveness of this approach. A retrospective, multi-center cohort study was conducted on cases performed from January 2013 to April 2021. Patients with direct inguinal hernias (M3 according to EHS classification) undergoing TAPP were included. Three groups were present: closed-defect group, non-closed placing a standard-sized mesh group or non-closed placing an XL-sized mesh group. A 2-year follow-up was recorded. A total of 158 direct M3 inguinal hernias in 110 patients who underwent surgery were present. After propensity score matching at a 1:1 ratio, 22 patients for each group were analyzed. The mean age of patients was 62 years (41-84); with the majority being male (84.8%). 22 patients (40 hernias) underwent closure of the defect; 22 patients (39 hernias) did not undergo closure and used a standard-sized mesh; 22 patients (27 hernias) did not undergo closure and used an XL-sized mesh. There were 5 recurrences at 1 year post-operatively: all in the non-closure group with standard-sized mesh. This difference was statistically significant (p = 0.044). There were 7 recurrences (6.6%) at 2 years post-operatively: 6 in the non-closure group with standard-sized mesh and 1 in the non-closure group with XL-sized mesh (p = 0.007). Closing large direct inguinal hernia defects has shown promise in reducing early recurrence rates. However, conducting larger RCTs in the future could provide more conclusive evidence that might impact the way we approach laparoscopic inguinal hernia repair.

State of the Art: Advances in Hernia Care

The field of hernia surgery has seen many recent advances and continues to evolve. Care of the hernia patient begins preoperatively by ensuring adequate preparation for surgery with surgeons now having the opportunity to accurately predict risk which can aid with informed consent. Imaging studies can now help surgeons diagnose and plan hernia surgery on an individual level based on hernia characteristics as well as abdominal wall musculature. In the operating room, new technology and surgical techniques have allowed surgeons to become increasingly sophisticated with goals of reducing tension on midline closures, utilizing minimally invasive and robotic techniques, and availability of new and varied mesh prosthetics. While modest improvements in outcomes have been witnessed by these advances, there is still opportunity for improvement which will be realized by continued research, use of registries, and education and training. Hernia prevention strategies focusing on minimally invasive surgery, laparotomy closure, and the use of prophylactic mesh will also help with the burden of incisional hernias. These advances in hernia surgery have led to the new field of Abdominal Core Health which helps represent this evolving and growing new subspecialty of general surgery.

Minimally Invasive Stapled Abdominal Wall Repair: A New Surgical Technique

Background: Diastasis recti (DR) is a common condition, especially in women after pregnancy, often associated with concomitant hernia defects and defined as a rupture of the midline and a separation of the rectus muscle more than 2 cm. Symptoms related to this are low back pain, urinary incontinence and pelvic prolapse, as well as abdominal bulging and core instability. We analyzed clinical and functional outcomes after treatment of DR alone or associated with midline hernias in 219 patients who underwent a midline reconstruction using miSAR® technique (minimally invasive stapled abdominal wall reconstruction). Methods: Between April 2019 and April 2022, 219 patients were treated with miSAR®. All patients were requested to quantify preoperative and postoperative functional symptoms (urinary incontinence, low back pain, abdominal swelling, and respiratory distress). Results: Twenty-seven men and 192 women underwent the miSAR® technique. The mean body mass index was 23.9 kg/m2. We performed the miSAR® technique in patients affected by incisional midline hernia and umbilical hernia alone or associated with DR. Composite mesh was used in 91.8% of cases. The average operating time was 90 minutes. Seven percent of the patients had postoperative complications, including two retromuscular hematomas, two retromuscular seromas, and one postoperative bleeding event. Two patients were readmitted for bowel obstruction. After surgery, there was symptomatic improvement in urinary incontinence, low back pain, respiratory symptoms, and abdominal swelling; this improvement was confirmed at 6 months and at 1- and 2-year follow-up. At the 1-year follow-up, the overall recurrence rate was 2.83%. Conclusion: miSAR® is a feasible and effective technique and shows promising results in the treatment of DR and ventral hernia. Possible enhancements include use of preoperative Botox to treat defects larger than 6 cm. Multicentric analysis is needed to validate the technique, and longer follow-up is required to assess the recurrence rate.

[Ventral Hernia Repair in Endoscopically Total Extrapertoneal Technique (eTEP) - Evaluation of Postoperative Outcome and One Year Follow-up]

BACKGROUND

Several recent meta-analyses have identified the retromuscular plane as the preferred mesh position in ventral hernia repair. Open surgery used to be the standard technique for these procedures. However, new minimally invasive techniques with totally extraperitoneal access and mesh positioning in the retromuscular plane have evolved.

METHODS

Between September 2018 and March 2019, 18 consecutive patients with ventral hernia were treated endoscopically in the totally extraperitoneal technique. Depending on the localisation and size of the hernia, the appropriate access was chosen and an uncoated mesh was placed in the retromuscular space in all patients. Data of patients' characteristics as well as peri- and postoperative parameters were collected. One year after surgery, patients were asked about recurrence, pain and complications, using the questionnaire of the herniamed data base.

RESULTS

No intraoperative complications were noted. Postoperatively, there was one retromuscular seroma that did not need treatment, one temporary paralysis of the radial nerve and one pulmonary embolism. None of these complications led to persistent problems. 17 of 18 patients were available for follow-up. One year follow-up showed no hernia recurrence. One patient had pain at rest requiring treatment.

CONCLUSIONS

Totally extraperitoneal endoscopic hernia surgery is a safe and promising new technique that is also feasible in complex hernias and with satisfactory 1 year results. This technique can combine the advantages of minimally invasive surgery with those of extraperitoneal mesh placement.

Early results of eTEP access surgery with preperitoneal repair of primary midline ventral hernias and diastasis recti. A 33 patient case series of "PeTEP"

BACKGROUND

This article aims to share the initial experience of the preperitoneal eTEP approach and its potential benefits in a selected group of patients. The eTEP Rives-Stoppa is a proven minimally invasive surgical technique for the treatment of ventral midline and off-midline hernias that has shown to be a solid, durable, and reproducible repair. The preperitoneal eTEP repair is a surgical technique that brings together the extraperitoneal access surgery with a preperitoneal repair for primary midline hernias avoiding posterior rectus sheath division and preservation of the retrorectus space while being able to treat simultaneous diastasis recti.

METHODS

The analysis included 33 patients operated with the preperitoneal eTEP approach from September 2022 to September 2023 in patients with primary small to medium (< 4 cm) midline hernias, single or multiple defects with or without diastasis recti. Age, gender, hernia characteristics, operative time, and surgical site occurrences will be discussed, as well as fine details and landmarks in the operative technique.

RESULTS

33 consecutive patients were operated, 19 female (57.5%) and 14 males (42.5%) between 32 and 63 years of age, the most common comorbidity found was obesity (BMI > 30). In 70% of the cases, operative time was 90 min ± 25 min. The average hospital stay was one day, while 12 went home the same day, and so far, no reoccurrences have been reported.

CONCLUSIONS

We believe the preperitoneal eTEP approach for small to medium primary midline hernias is an effective and solid repair that combines excellent features of proven surgical techniques and eliminates the need for posterior rectus sheath division while saving the retrorectus space, among other benefits that will be discussed. The reproducibility of the technique remains to be proven.

Laparoscopic intraperitoneal onlay mesh (IPOM) with fascial repair (IPOM-plus) for ventral and incisional hernia: a systematic review and meta-analysis

PURPOSE

Despite advancements in laparoscopic ventral hernia repair (LVHR) using the intraperitoneal onlay mesh technique (sIPOM), recurrence remains a common postoperative complication. The objective of this systematic review and meta-analysis is to compare the efficacy of defect closure (IPOM-plus) versus non-closure in ventral and incisional hernia repair. The aim is to determine which technique yields better outcomes in terms of reducing recurrence and complication rates.

METHODS

A comprehensive literature review was conducted in the PubMed, Web of Science, Cochrane Library, Embase, and ClinicalTrials.gov databases from their inception until October 1, 2022, to identify all online English publications that compared the outcomes of laparoscopic ventral hernia repair with and without fascia closure.

RESULTS

Three randomized controlled trials (RCTs) and eleven cohort studies involving 1585 patients met the inclusion criteria. The IPOM-plus technique was found to reduce the recurrence of hernias (OR = 0.51, 95% CI [0.35, 0.76], p < 0.01), seroma (OR = 0.48, 95% CI [0.32, 0.71], p < 0.01), and mesh bulging (OR = 0.08, 95% CI [0.01, 0.42], p < 0.01). Subgroup analysis revealed that body mass index (BMI) (OR = 0.43, 95% CI [0.29, 0.65], p < 0.0001), type of article (OR = 0.51, 95% CI [0.35, 0.76], p = 0.0008 < 0.01), geographical location (OR = 0.54, 95% CI [0.36, 0.82], p = 0.004 < 0.01), follow-up time (OR = 0.50, 95% CI [0.34, 0.73], p = 0.0004 < 0.01) had a significant influence on the postoperative recurrence of the IPOM-plus technique.

CONCLUSION

The IPOM-plus technique has been shown to greatly reduce the occurrence of recurrence, seroma, and mesh bulging. Overall, the IPOM-plus technique is considered a safe and effective procedure. However, additional randomized controlled studies with extended follow-up periods are necessary to further evaluate the IPOM-plus technique.

Inside to outside puncture following endoscopic localization-A novel technique to insert ports and create retromuscular space in eTEP for ventral hernias

PURPOSE

Enhanced-view totally extraperitoneal plasty (eTEP) has been used worldwide to repair ventral hernias. This study aimed to describe a novel technique to insert ports and create retromuscular space in more detail.

METHODS

From 2020 to 2022, 23 consecutive ventral hernia repairs were performed using the eTEP technique. In all cases, inside-to-outside puncture following endoscopic localization was utilized to insert ports and create retromuscular space.

RESULTS

All cases were completed with the eTEP technique, and no cases with conversion to open repair or IPOM technique. There were no epigastric vessel injuries and posterior sheath tears due to puncture. In addition, no postoperative hematoma cases were reported.

CONCLUSION

Inside-to-outside puncture following endoscopic localization to insert ports and create retromuscular space is a safe, feasible, reproducible technique in eTEP for ventral hernia repair.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a 5-10-year follow-up of the randomized controlled multicenter study

PURPOSE

In this long-term follow-up of a prospective, randomized, and multicenter study, we compare the results of a group receiving laparoscopic incisional ventral hernia repair using intraperitoneal onlay mesh (LG) to a group receiving a hybrid hernia repair where open closure of fascial defect was added to intraperitoneal mesh placement (HG).

METHODS

Originally, 193 patients with 2-7 cm incisional hernias were randomly assigned to either the LG or HG during the 30-month recruitment period in 2012 to 2015. Long-term follow-up was conducted 5-10 years after surgery to evaluate hernia recurrence rate and quality of life (QoL).

RESULTS

In all, 65 patients in the LG and 60 in the HG completed the long-term follow-up with a median follow-up period of 87 months. Recurrent hernia was detected in 11 of 65 patients (16.9%) in the LG and 10 of 60 patients (16.7%) in the HG (p  >  0.9). Kaplan-Meier analysis demonstrated a recurrence rate approaching 20% in both groups, with similar curves. Three patients in the LG (4.6% and five patients in the HG (8.1%) had undergone re-operation due to recurrence (p  = 0.48). There was no difference in patient-reported QoL measured using the SF-36 questionnaire. Mean pain scores were similar between groups, mean numeric rating scale (NRS) 0 to 10 being 1.1 in the LG and 0.7 in the HG (p  = 0.43).

CONCLUSION

Fascial closure did not reduce hernia recurrence rate in this study population, even though it has been shown to be beneficial and recommended in surgery guidelines. In the long term, recurrence rate for both groups is similar.

Laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique versus intraperitoneal onlay mesh (IPOM plus) for ventral hernia repair: a comparative analysis

PURPOSE

Primary aim of this study is to compare the postoperative outcomes of the laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique to the intraperitoneal onlay mesh closing the defect (IPOM plus), in terms of recurrence and bulging rates at one-year follow-up; secondary aim is to compare the postoperative complications, seroma and pain at 30 days and one-year after surgery.

METHODS

Patients with midline ventral hernia of 4-10 cm in width were included. Computed tomography scan was performed before, 1 and 12 months after surgery. Pain was evaluated using the visual analogue scale.

RESULTS

Forty-five and forty-seven consecutive patients underwent LIRA and IPOM plus, respectively. Preoperatively, smoke habits and chronic obstructive pulmonary disease rates were statistically significantly higher in the LIRA group (p = 0.0001 and p = 0.012, respectively). Two bulgings (4.4%) occurred in the LIRA group, while in the IPOM plus group occurred 10 bulgings (21.3%) and three recurrences (6.4%) (p = 0.017 and p = 0.085, respectively). Postoperatively, seven (15.6%, Clavien-Dindo I) and four complications (8.5%, two Clavien-Dindo I, two Clavien-Dindo III-b) occurred in the LIRA and in the IPOM plus group, respectively (p = 0.298). One month after surgery, clinical seroma, occurred in five (11.1%) and eight patients (17%) in the LIRA and in the IPOM plus group, respectively (p = 0.416). During follow-up, pain reduction occurred, without statistically significant differences.

CONCLUSIONS

In this study, even if we analysed a small series, LIRA showed lower bulging and recurrence rates in comparison to IPOM plus at one-year follow-up. Further prospective studies, with a large sample of patients and longer follow-up are required to draw definitive conclusions.

Comparison of Laparoscopic Intraperitoneal Onlay Mesh (IPOM) Hernioplasty With Laparoscopic IPOM-Plus: Our Initial Experience in Pakistan

Objectives Laparoscopic intraperitoneal onlay mesh hernioplasty (IPOM) for ventral hernias has been used for a long time. However, there have been some issues associated with it, thereby leading to the introduction of a new technique that involves laparoscopic closure of the fascial defect with suture followed by intraperitoneal onlay mesh placement (IPOM-Plus). We carried out this study to compare the outcome of laparoscopic IPOM with fascial defect closure versus without defect closure in midline ventral hernia repair in terms of recurrence. Methodology This comparative study was carried out in the Department of Surgery, Services Hospital, Lahore, from October 16, 2020, to April 15, 2022. A total of 84 patients of both genders, aged between 18 and 70 years, presenting with midline ventral hernia were included in the study. Patients with recurrent hernia, unstable cardiopulmonary conditions, neurological or psychiatric diseases, chronic renal disease, congestive cardiac failure, and chronic obstructive pulmonary disease (COPD) were excluded from the study. Patients were assigned to two groups. Group 1 underwent IPOM with the closure of the defect, and Group 2 underwent IPOM without the closure of the defect. Patients were observed for immediate postoperative complications. Patients were monitored for one year to assess recurrence through clinical evaluation and ultrasonography. Results In this study, seroma formation was found in 3 (7.14%) patients for laparoscopic IPOM with fascial defect closure and 10 (23.81%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.035). Recurrence was identified in 2 (4.76%) patients undergoing laparoscopic IPOM with fascial defect closure and 9 (21.43%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.024). Conclusions This study concluded that the frequency of recurrence is less after laparoscopic IPOM with fascial defect closure in midline ventral hernia repair than after laparoscopic IPOM without fascial defect closure.

[Incisional hernias: minimally invasive surgical procedures]

BACKGROUND

In recent years many new surgical techniques for minimally invasive treatment of ventral hernias have been developed and introduced. This review article presents these new minimally invasive surgical techniques, such as extended totally extraperitoneal (eTEP) repair, mini or less open sublay (MILOS), endoscopic-assisted linea alba reconstruction (ELAR), the ventral transabdominal preperitoneal patch (TAPP) technique, intraperitoneal onlay mesh (IPOM) plus and laparoscopic intracorporeal rectus aponeuroplasty (LIRA) and discusses recently published results.

RESULTS

Modern minimally invasive techniques for the treatment of ventral hernias have the potential to reduce surgical site infections, lower postoperative pain and lead to a shorter duration of hospital stay compared to the classical open hernia repair; however, especially techniques with a retromuscular mesh position are technically challenging due to the preparation in a limited space and difficult to perform endoscopic sutures and necessitate detailed knowledge of the anatomy of the abdominal wall. The treatment of larger hernias in particular should therefore only be carried out under the prerequisite of extensive experience and case numbers.

CONCLUSION

The new endoscopic and endoscopically assisted techniques for treatment of ventral hernias enable the experienced laparoscopic surgeon to primarily and secondarily treat ventral hernias with minimally invasive techniques.

Trends in Use of Laparoscopic Intraperitoneal Onlay Mesh for Ventral Hernia Repair

This cohort study examines changes in the proportion of laparoscopic intraperitoneal onlay mesh procedures performed for hernia repair in Denmark since initial description of the procedure.

Analysis of recurrence and risk factors in laparoscopic sandwich technique for parastomal hernia repair

INTRODUCTION

Parastomal hernias are frequent and highly recurrent. The sandwich technique is a combination of the keyhole and Sugarbaker techniques, using a double intraperitoneal mesh. The objective of this study was to assess the outcomes of the sandwich technique, specifically focusing on recurrence rates.

MATERIALS AND METHODS

Observational retrospective study conducted in two tertiary referral centers in Catalonia, Spain. All consecutive patients who underwent parastomal hernia repair using the sandwich technique between 1st January 2016 and 31st December 2021 were included.

RESULTS

A total of 38 patients underwent the laparoscopic sandwich technique for parastomal hernia repair. The overall recurrence rate was 7.9% (3/38), with a median follow-up of 39 months (IQR: 12.3-56.5). According to the EHS classification for parastomal hernia, there were 47.4% (18/38) type I defects, 10.5% (4/38) type II defects, 28.9% (11/38) type III defects, and 13.2% (5/38) type IV defects. The used mesh was predominantly TiMesh® (76.3%; 29/38), followed by DynaMesh® IPOM (23.7%; 9/38). Patients with recurrence exhibited higher rates of seroma, hematoma, surgical site infection, and one case of early recurrence attributed to mesh retraction. Consequently, postoperative complications emerged as the primary risk factor for hernia recurrence.

CONCLUSION

The sandwich technique demonstrated recurrence rates consistent with those reported in the existing literature.

The effect of an abdominal binder on postoperative outcome after open incisional hernia repair in sublay technique: a multicenter, randomized pilot trial (ABIHR-II)

INTRODUCTION

Although the evidence is minimal, an abdominal binder is commonly prescribed after open incisional hernia repair (IHR) to reduce pain. This study aimed to investigate this common postoperative treatment.

METHODS

The ABIHR-II trial was a national prospective, randomized, multicenter non-AMG/MPG pilot study with two groups of patients (wearing an abdominal binder (AB) for 2 weeks during daytime vs. not wearing an AB following open IHR with the sublay technique). Patient enrollment took place from July 2020 to February 2022. The primary endpoint was pain at rest on the 14th postoperative day (POD) using the visual analog scale (VAS). The use of analgesics was not systematically recorded. Mixed-effects linear regression models were used.

RESULTS

A total of 51 individuals were recruited (25 women, 26 men; mean age 61.4 years; mean body mass index 30.65 kg/m2). The per-protocol analysis included 40 cases (AB group, n = 21; No-AB group, n = 19). Neither group showed a significant difference in terms of pain at rest, limited mobility, general well-being, and seroma formation and rate. Patients among the AB group had a significantly lower rate of surgical site infection (SSI) on the 14th POD (AB group 4.8% (n = 1) vs. No-AB group 27.8% (n = 5), p = 0.004).

CONCLUSION

Wearing an AB did not have an impact on pain and seroma formation rate but it may reduce the rate of postoperative SSI within the first 14 days after surgery. Further trials are mandatory to confirm these findings.

Ventralex™ ST Hernia Patch Repair for Small Umbilical Hernia is Safe and Effective: A Retrospective Cohort Study

Background: Hernia patches for umbilical hernia repair have gained popularity due to their short operation time and ease of use. However, up to 10% re-operation and 8% recurrence rates at 2-year follow-up have been published. This retrospective cohort study presents the long-term results of the hernia patch technique for umbilical hernia repair. Methods: All adult patients who underwent a primary umbilical hernia repair at Oulu University Hospital hernia surgery units during 2014-2018 were included in the study. The primary outcome measure was recurrence rate. Secondary outcomes were complications and re-operation rate. Results: A total of 619 elective primary umbilical hernia repairs were performed during 2014-2018. The major technique used was Ventralex™ ST hernia patch repair (79.0%, 488/619) for small hernias with a mean width of 1.8 (SD 0.79) cm. Most of the patches (84.7%, 414/488) were placed in the preperitoneal space. Hernia recurrence rate of patient operated on using Ventralex™ ST hernia patch was 2.5% (12/488) during a mean follow-up time of 68 (SD 16, 43-98) months. Re-operation rate for another reason than recurrence was 1.6% (8/488). Clavien-Dindo complications ≥3 occurred in 4.1% (20/488) of cases and surgical site infection rate was 3.3% (16/488). Conclusion: Umbilical hernia repair using a Ventralex™ ST hernia patch placed in preperitoneal space have acceptable results in terms of recurrence and re-operations in this cohort study.

IPOM plus versus IPOM standard in incisional hernia repair: results of a prospective multicenter trial

PURPOSE

Laparoscopic ventral hernia repair is a well-established technique with satisfying outcomes even at long term for the treatment of incisional and ventral hernia. However, the literature debate is still ongoing regarding the preferred surgical technique. Nowadays, two approaches are commonly adopted: the intraperitoneal onlay mesh repair (sIPOM) and the intraperitoneal onlay mesh reinforcement with defect closure before mesh placement (pIPOM). The aim of this prospective analysis is to compare the postoperative outcomes of patients treated for incisional hernia (IH) with sIPOM and pIPOM after 36 months follow-up in terms of recurrence, quality of life and wound events.

METHODS

Patients receiving pIPOM and sIPOM for IH were actively followed up for 36 months. At the outpatient clinic, hernia recurrence (HR), mesh bulging (MB), quality of life with the Gastrointestinal Quality of Life Index (GIQLI) and wound events were assessed.

RESULTS

Between January 2015 and January 2019, 98 patients underwent a pIPOM and 89 underwent an sIPOM. At 36 months, nine patients (4 in pIPOM and 5 in sIPOM) experienced an HR, while MB was recorded in four patients in pIPOM and nine in sIPOM. No statistically significant difference could be identified also in terms of final GIQLI score and wound events.

CONCLUSIONS

LVHR with or without fascial closure, also in our study, provides satisfactory results in terms of safety and efficacy. The discordant results in the literature are probably related to independent variables such as the type of mesh, the type of suture and closure technique. Therefore, was the funeral of sIPOM done too early? STUDY DATASET IS AVAILABLE ON CLINICALTRIALS.

GOV ID

NCT05712213.

Laparoscopic treatment of ventral hernias: the Italian national guidelines

Primary and incisional ventral hernias are significant public health issues for their prevalence, variability of professional practices, and high costs associated with the treatment In 2019, the Board of Directors of the Italian Society for Endoscopic Surgery (SICE) promoted the development of new guidelines on the laparoscopic treatment of ventral hernias, according to the new national regulation. In 2022, the guideline was accepted by the government agency, and it was published, in Italian, on the SNLG website. Here, we report the adopted methodology and the guideline's recommendations, as established in its diffusion policy. This guideline is produced according to the methodology indicated by the SNGL and applying the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Fifteen recommendations were produced as a result of 4 PICO questions. The level of recommendation was conditional for 12 of them and conditional to moderate for one. This guideline's strengths include relying on an extensive systematic review of the literature and applying a rigorous GRADE method. It also has several limitations. The literature on the topic is continuously and rapidly evolving; our results are based on findings that need constant re-appraisal. It is focused only on minimally invasive techniques and cannot consider broader issues (e.g., diagnostics, indication for surgery, pre-habilitation).

Fascia defect closure versus non-closure in minimal invasive direct inguinal hernia mesh repair: a systematic review and meta-analysis of real-world evidence

PURPOSE

Laparoscopic and robotic inguinal hernia mesh repair are both common surgical procedures worldwide. Postoperative hernia recurrence and seroma formation are important concerns. In ventral hernia, primary defect closure in laparoscopic surgery reduces the recurrence rate. However, there is no synthetic evidence of direct inguinal hernia defect closure versus non-closure in minimal invasive surgery. Therefore, this study investigated the efficacy of defect closure in patients undergoing minimal invasive direct inguinal hernia mesh repair.

METHODS

Eligible studies were identified through a search of PubMed, Embase, Cochrane Library, and CINAHL from their inception until March 2022. Studies examining defect closure in laparoscopic direct inguinal hernia repair were included, and a meta-analysis was performed using the random-effect model. Sensitivity analyses were performed by removing one study at a time. The primary outcomes were hernia recurrence and seroma formation. Acute and chronic postoperative pain, operation time, and length of hospital stay were the secondary outcomes.

RESULTS

Five nonrandomized studies and one randomized controlled trial were included. Pooled analysis revealed defect closure might reduce the hernia recurrence rate (risk difference, - 0.02; 95% confidence interval [CI] - 0.04 to - 0.00; p = 0.02). The result of seroma formation (odds ratio, 0.49; 95% CI 0.17-1.46; p = 0.20) showed no significant difference. Moreover, no significant differences were observed in acute postoperative pain, chronic pain, length of hospital stay, and operation time.

CONCLUSIONS

Our study indicated defect closure seems to be an option to reduce the direct inguinal hernia recurrence rate. No significant benefits were shown in seroma formation and other secondary outcomes. Our study was mostly based on nonrandomized studies and underestimated the effect of defect closure; thus, further high-quality studies are required to draw definitive conclusions.

Postoperative virtual pressure difference as a new index for the risk assessment of liver resection from biomechanical analysis

In the realm of hepatectomy, traditional methods for postoperative risk assessment are limited in their ability to provide comprehensive and intuitive evaluations of donor risk. To address this issue, there is a need for the development of more multifaceted indicators to assess the risk in hepatectomy donors. In an effort to improve postoperative risk assessments, a computational fluid dynamics (CFD) model was developed to analyze blood flow properties, such as streamlines, vorticity, and pressure, in 10 eligible donors. By comparing the correlation between vorticity, maximum velocity, postoperative virtual pressure difference and TB, a novel index - postoperative virtual pressure difference - was proposed from a biomechanical perspective. This index demonstrated a high correlation (0.98) with total bilirubin values. Donors who underwent right liver lobe resections had greater pressure gradient values than those who underwent left liver lobe resected donors due to the denser streamlines and higher velocity and vorticity values of the former group. Compared with traditional medical methods, the biofluid dynamic analysis using CFD offers advantages in terms of accuracy, efficiency, and intuition.

Ring closure outcome for laparoscopic ventral hernia repair (IPOM plus) in medium and large defects. Long-term follow-up

BACKGROUND

Despite advances in laparoscopic ventral hernia repair (LVHR) with the Intra-peritoneal onlay mesh technique (IPOM), recurrence continues to be a frequent postoperative complication. The aim of this study is to analyze the long-term recurrence rate in two series, by incorporating in IPOM technique the laparoscopic closure of the defect (IPOM plus). We also want to determine the ring size cut-off point from which the recurrence risk increases in IPOM technique and determine if the cut-off point is modified with IPOM plus technique.

METHODS

A comparative retrospective study was conducted analyzing patients who underwent LVHR. They were divided into 2 groups according to the surgical technique used: IPOM or IPOM plus. We determined in each group the cut-off point where the ring size presents a greater recurrence risk by calculating the better point of sensitivity/specificity relationship of the ROC curve.

RESULTS

Between 2007 and 2018, 286 patients underwent LVHR. The ROC curve for IPOM technique has shown a cut-off point of higher recurrence risk for rings larger than 63 cm2. While the ROC curve in IPOM plus group showed an increase in the cut-off point, with a higher recurrence risk in rings > 168 cm2. Overall median ring size was 30 cm2 (range 4-225; IQR 16-61). However, when comparing the ring size between techniques we found a relatively larger size in IPOM plus (p: 0.013). The recurrence rate in the IPOM group was 19.51% while in the IPOM plus group was 3.57% (p: 0.005).

CONCLUSIONS

For standard LVHR with IPOM technique, the greatest recurrence risk occurs in rings larger than 63 cm2. The addition of ring closure (IPOM plus) was associated with a recurrence risk reduction, which occurs in rings larger than 168 cm2. These findings would allow expanding the indication for LVHR, using the IPOM plus technique.

Laparoscopic Intraperitoneal Onlay Mesh (IPOM): Short- and Long-Term Results in a Single Center

The laparoscopic intraperitoneal onlay mesh repair (IPOM) approach has become the most widely adopted technique in the last decade. The role of laparoscopic IPOM in the last years has been resizing due to several limitations. The aim of the present study is to evaluate short- and long-term outcomes in patients who underwent laparoscopic IPOM. This retrospective single-center study describes 170 patients who underwent laparoscopic IPOM for ventral hernia at the General Surgery Unit of Parma University Hospital from 1 January 2016 to 31 December 2020. We evaluated patient, hernia, surgical and postoperative characteristics. According to the defect size, we divided the patients into Group 1 (Ø < 30 mm), Group 2 (30 < Ø < 50 mm) and Group 3 (Ø > 50 mm). A total of 167 patients were included. The mean defect diameter was 41.1 ± 16.3 mm. The mean operative time was different among the three groups (p < 0.001). Higher Charlson Comorbidity Index, obesity and incisional hernia were related to postoperative seroma and obesity alone with SSO. p < 0.001 Recurrence was significantly higher in larger defects (Group 3) and incisional hernia. p < 0.001. This retrospective study suggests that laparoscopic IPOM is a feasible and safe surgical technique with an acceptable complication rate, especially in the treatment of smaller defects up to 5 cm.

Primary closure of the midline abdominal wall defect during laparoscopic ventral hernia repair: analysis of risk factors for failure and outcomes at 5 years follow-up

BACKGROUND

The primary aim of this prospective study is to report bulging and recurrence rates and to analyze the risk factors responsible for failure, after laparoscopic ventral hernia repair (LVHR) with primary closure of defect (PCD) using a running suture and intraperitoneal mesh placement, at 5-year follow-up. The secondary endpoint is to evaluate 30-day postoperative complications, seroma, and pain.

METHODS

PCD failure was defined as the presence of postoperative bulging and/or recurrence. Pain was evaluated using a visual analogue scale (VAS). After surgery, fifty-eight patients underwent clinical examination and computed tomography scan to diagnose bulging, recurrence, and seroma (classified according to the Morales-Conde classification).

RESULTS

At 60 months follow-up, recurrence was observed in five patients (8.6%), while bulging, not needing a surgical treatment, occurred in fifteen patients (25.9%). Chronic obstructive pulmonary disease (COPD) is the only risk factor responsible for both outcomes together, bulging and recurrences (p = 0.029), while other considered risk factors as gender, age, body mass index, diabetes, smoke habits, primary or incisional hernia and the ratio defect width/transverse abdominal axis did not achieve the statistically significance. Clinical seroma was diagnosed at one month in eight patients (13.8%). Seromas were observed at one year of follow-up. During the follow-up, pain reduction occurred.

CONCLUSION

LVHR has evolved toward more anatomical concepts, with the current trend being the abdominal wall anatomical reconstruction to improve its functionality, reducing seroma rates. Based on results obtained, PCD is a reliable technique with excellent recurrence rate at 5 years follow-up, even when the defect closure may generate tension at the midline. On the other hand, this tension could be related with high bulging rate at long-term, particular in case of patients with COPD.

Practice and short-term outcomes in ventral hernia repair: a prospective multicenter data audit of Indian Association of Gastrointestinal Endo Surgeons Research Collaborative

INTRODUCTION

There is considerable variation in the practice of ventral hernia repair (VHR). Consequently, both short- and long-term outcomes are different. We report the first multicenter data from India on the variations in procedures and short-term outcomes after ventral hernia repair.

METHODS

A prospective study was planned under the aegis of the Indian Association of Gastrointestinal Endo Surgeons (IAGES). Participating surgeons prospectively recorded the data of patients who underwent VHR from January 21, 2021, to April 20, 2021. Patients were followed for 3-6 months.

RESULTS

Data from 648 patients were analyzed for demographics, hernia characteristics, technical variations, and outcomes. 375 (57.8%) were primary hernias (PH) and 273 (42.15%) were incisional hernias (IH), of which 63 (9.7%) were recurrent hernias. In the PH group, there were 171 minimal access (MAS) and 170 open repair. In descending order of frequency, there were 111 (32.6%) open onlay, 83 (24.3%) intraperitoneal onlay meshplasty (IPOM) Plus, 36 (10.6%) IPOM, 35 (10.3%) suture repair, 22 (6.5%) endoscopic Rives Stoppa (eRS), 11 (3.2%) open RS, 11 (3.2%) TAPP, 7 (2%) hybrid, 6 (1.8%) open preperitoneal, 19 (5.6%) others. There were 3.73% seroma, 3.2% SSI, 0% 90-day readmission, 0% recurrence, and 0.3% mortality. In the IH group, 164 patients underwent open repair and 104 MAS repair. In descending order of frequency, there were 90 (33.6%) open onlay, 47 (17.5%) IPOM Plus, 38 (14.1%) open sublay, 28 (10.4%) IPOM, 12 (4.5%) Transversus Abdominis Release (TAR), 11 (4.1%) suture repair, 9 (3.4%) open preperitoneal, 7 (2.6%) hybrid, 6 (2.2%) TAPP, 5 (1.9%) eRS, 4 (1.5%) TARM, 3 (1.1%) endoscopic TAR (eTAR), and 8 (3%) others. There were 13.92% seroma, 4.4% hematoma, 9.5% SSI, 1.1% mesh explantation, 0.4% wound sinus, 2.2% 90-day readmission, 0% recurrence, and 1.1% mortality.

CONCLUSION

Onlay meshplasty is the commonest procedure in India both in PH and IH. IPOM/IPOM plus is the second commonest procedure. TAR is the preferred component separation technique. Complication rates were comparable to published literature.

TRIAL REGISTRATION

The study was registered with Clinical Trial Registry of India. CTRI number-CTRI/2021/01/030435.

Tension-reduced closure of large abdominal wall defect caused by shotgun wound: A case report

BACKGROUND

Large abdominal wall defect (LAWD) caused by shotgun wound is rarely reported.

CASE SUMMARY

Herein, we describe a case of LAWD caused by a gunshot wound in which the abdominal wall was reconstructed in stages, including debridement, tension-reduced closure (TRC), and reconstruction with mesh and a free musculocutaneous flap. During a 3-year follow-up, the patient recovered well without hernia or other problems.

CONCLUSION

TRC is a practical approach for the temporary closure of LAWD, particularly in cases when one-stage abdominal wall restoration is unfeasible due to significant comorbidities.

Three-year prospective outcomes of laparoscopic intraperitoneal on-lay mesh repair of abdominal incisional hernia

BACKGROUND

Incisional hernia (IH) can be treated with an intraperitoneal on-lay mesh (IPOM). This study aimed to evaluate the surgical outcomes, recurrence rates, and chronic pain after laparoscopic IH repair.

METHOD

The data of 50 patients who underwent laparoscopic IPOM repair between March 2018 and May 2021 were prospectively collected.

RESULTS

The standard IPOM technique was used on 41 patients (82%), whereas the IPOM-plus technique was used on nine patients (18%). There was a history of IH repair for 12 patients (24%), and two of them recurrent hernias. The average body mass index was 24.7, and the average defect size was 17.6 cm² . The mean operative time was 145.7 minutes, and the mean hospital stay was 3.5 days. There were minor complications in nine patients (18%), a case of bowel injury (2%), and a case of bladder injury (2%). Recurrent hernias were observed in three patients (6%) over a mean follow-up period of 17.9 months (4-36 months). One patient had postoperative chronic pain lasting 3 months. The width and size of the hernia were risk factors for recurrence.

CONCLUSION

Laparoscopic IPOM repair was a safe and effective method of treating IH, with a low incidence of postoperative complications, chronic pain, and recurrence.

Ventral hernia repair with a hybrid laparoscopic technique

BACKGROUND

Ventral hernias are increasingly managed with minimally invasive laparoscopic surgery. Invasive open surgery is typically used for the repair of large-sized hernias (>10 cm diameter). The two methods are often considered mutually exclusive. We report a hybrid technique for repair of medium to large-sized hernias.

METHODS

Data was collected prospectively from 44 hernias repaired using the hybrid technique from 2012 to 2020. Operative data was examined and follow-up conducted by both clinical and phone review. As for surgical technique, laparoscopic access was established via a 5 mm optical port and two (or more) 5 mm ports were added under vision. Hernia contents were reduced and extraperitoneal fat excised around the defect. Hernias with diameters ranging from 5 to 10 cm were fixed using the hybrid technique. A small incision was made directly over the hernia and polyester mesh was placed intraabdominally before defect closure with a transfascial suture. Pneumoperitoneum was re-established and mesh fixation achieved using absorbable tacks and/or fixation sutures.

RESULTS

Of the 44 ventral hernias repaired with the hybrid technique, 43 were secondary hernias from incisional defects. Average hernia diameter was 6.6 cm. 86% of patients were discharged within the first 48 h. Four patients (9%) had recurrences during the study period. Minor complications occurred in 8 patients (18%): 3 (7%) had post-operative wound infection, 3 patients (7%) developed post-operative seroma. Two patients (5%) had clinically significant wound haematoma.

CONCLUSION

Laparoscopic hybrid ventral hernia repair can be safely performed by a combination of laparoscopic and open techniques, offering an alternative method in the management of medium-sized ventral hernias.

Modified keyhole plus technique with partial release of posterior rectus sheath for parastomal hernia repair after ileal conduit

Parastomal hernia (PH) is a common complication of ileal conduit diversions. The Sugarbaker technique has a lower recurrence rate than the keyhole (KH) technique and is typically preferred. However, it may not be feasible in some cases because of anatomical features including the length of the conduit and torsion of the ureter. An 80-year-old woman with complaints of abdominal distention was diagnosed with PH 5 years after radical cystectomy. Computed tomography revealed a 90 × 20-mm muscular layer defect on the cranial side of the ileal conduit. Therefore, we performed the KH technique with intracorporeal closure of the defect using a relief incision of the posterior rectus sheath, avoiding the possibility of torsion of the ureteral ileal anastomosis. No hernia recurrence was observed at postoperative 10 months. The proposed KH plus technique may be an effective method for PH after ileal conduit diversion, thus preventing urinary complications.

Robotic Intracorporeal Rectus Aponeuroplasty: Early Experience of a New Surgical Technique for Ventral Hernia Repair

Introduction: The laparoscopic intracorporeal rectus aponeuroplasty (LIRA) was developed as an alternative for minimally invasive ventral hernia repair. This technique allows the closure of the defect and restoration of the midline without tension by plication of both aponeurosis of the abdominal rectus muscles combined with a minimally invasive intraperitoneal underlay mesh repair. The objective of this study is to report our early experience with the Robotic-LIRA (R-LIRA) technique and its safety and short-term efficacy. Methods: We performed a retrospective analysis of patients undergoing R-LIRA repair for ventral hernias from March 2019 to April 2022. Results: Eight patients underwent R-LIRA from March 2019 to April 2022. Median age was 47 years (interquartile range [IQR] 34.5-62.8). Median body mass index was 34.2 kg/m² (IQR 29.9-35.2). Four patients (50%) had a primary ventral hernia being one M2, two M3, and one M2/M3. There were three incisional hernias, being one recurrent, 6 patients (75%) had associated diastasis of the rectus muscle and 1 patient presented pure diastasis. The median hernia width was 4 cm (IQR 2-6), and the median defect area was 16 cm² (IQR 4-42). The median mesh area was 290 cm² (IQR 211.2-300). In all cases, a barbed suture was also used for mesh fixation, and tackers were added in 4 cases. The median operative time was 172 minutes (IQR 139.8-293.3). The median length of stay was 0.5 days (IQR 0-1.8), and the median follow-up was 20 days (IQR 16-46). Conclusion: The R-LIRA has been shown to be safe and feasible for ventral and incisional hernia repairs with or without Diastasis of the Rectus Abdominis Muscle in the short term.

Midterm Results of the Open and Minimally Invasive Transversus Abdominis Release Technique for the Treatment of Abdominal Wall Hernias in an Academic Center

Introduction: Large hernia defects are a challenge for general and specialized hernia surgeons. The transversus abdominis release (TAR) technique has revolutionized the treatment of complex hernias since it allows the closure of large midline hernias, as well as hernias in different locations. This study aims to report the experience with the TAR technique and mid-term results in the first 101 patients. Methods: Non-concurrent cohort review of our prospectively collected electronic database. All patients submitted to a TAR (open or minimally invasive eTEP-TAR) from 2017 to 2020 were included. Demographic data, comorbidities, hernia characteristics, preoperative optimization, intraoperative variables, and clinical outcomes were gathered. The main outcomes of this study are hernia recurrences and surgical morbidity. Results: A total of 101 patients were identified. The median follow-up was 26 months. Mean age and body mass index was 63 years and 31.4 Kg/m2, respectively. Diabetes was present in 22% of patients and 43% had at least one previous hernia repair. Nineteen patients had significant loss of domain. Mean hernia size and area were 13 cm and 247 cm2, respectively. Ninety-six percent of cases were clean or clean-contaminated. The mean operative time was 164 min and all patients received a synthetic mesh. We diagnosed two hernia recurrences and the overall (medical and surgical) complication rate was 32%. The hernia-specific complication rate was 17%, with seven surgical site infections and seven surgical site occurrences requiring procedural interventions. Notably, weight loss was associated with a lower risk of SSOPI and reoperations. Conclusion: We show an encouraging 2% of recurrences in the mid-term follow-up in the setting of clinically complex hernia repair. However, we observed a high frequency of overall and hernia-specific complications pointing to the complexity of the type of surgery itself and the patients we operated on.

Comparison of outcomes of laparoscopic hernioplasty with and without fascial repair (IPOM-Plus vs IPOM) for ventral hernia: A retrospective cohort study

Background

Materials and methods

Results

Conclusions

•

IPOM repair comprises bridging the hernial defect from the peritoneal side with a composite mesh.

•

IPOM-Plus comprises suturing the defect in the fascia before placing the mesh.

•

Seroma formation, injury to bladder or bowel, and mesh bulging were higher after IPOM repair.

•

The AOR of six-month recurrence after IPOM repair was 14.86 times higher than that after IPOM-Plus repair.

•

IPOM-Plus can be preferred over IPOM for its better outcomes.

Endoscopic transversus abdominis release in the treatment of midline incisional hernias: a prospective single-center observational study on 100 patients

BACKGROUND

For W2-3 incisional hernias of the midline, a component separation is often needed to achieve closure of the fascia during repair with a mesh. Posterior component separation has been initially performed via open surgical approach, but more recently interest in minimally invasive reconstruction has grown. The aim of this work is to describe the technical aspects of endoscopic hernia repair with posterior component separation and to assess its feasibility in midline incisional hernias, based on the analysis of the results.

METHODS

We prospectively evaluated and analyzed patients with midline incisional hernias who underwent endoscopic posterior component separation by transversus abdominis release (TAR).

RESULTS

A group of 100 patients was operated between April 2017 and September 2021. The median follow-up was 27 ± 13.5 months, mean age 59 ± 10.2 years, ASA 2.5 ± 0.7; 94% of patients had comorbidity. There were 7 (7%) complications observed in the early postoperative period-retromuscular hematoma (1), infection of the retromuscular space (4), and thrombophlebitis of superficial veins (2). In 4 (4%) patients, late complications were observed-persistent seroma (3) and chronic pain (1). There were no hernia recurrences in the follow-up period.

CONCLUSION

The use of TAR endoscopic separation can reduce the number of unfavorable surgical site events, compared to the published data on a similar open surgery, while maintaining a low recurrence rate.

An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair

Purpose:  Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods:  A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results:  Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects. Rives-Stoppa sublay mesh repair has become the "gold" standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature. Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned. Conclusions:  Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.

Comparison of two fascial defect closure methods for laparoscopic incisional hernia repair

PURPOSE

Currently there is no consensus regarding the optimal surgical approach to an incisional hernia measuring less than 10 cm. Certain hernia features including defect size, intra-abdominal adhesions, and overlying scar/skin properties contribute to choosing an open versus a laparoscopic approach. This retrospective cohort study was designed to compare incisional hernia defects repaired with laparoscopic suture closure to a hybrid approach with open defect closure, both with laparoscopic intraperitoneal onlay mesh (IPOM) reinforcement.

METHODS

We identified 164 consecutive patients who underwent incisional hernia repair from two centers, North York General Hospital (NYGH) and Humber River Hospital (HRH) between 2015 and 2020. Patients were grouped by totally laparoscopic or hybrid fascial closure. Both techniques included laparoscopically placed intra-peritoneal mesh with 5 cm of overlap in all directions. Patients were analyzed by age, sex, body mass index (BMI), ASA class and hernia size. Primary outcomes included surgical site infection (SSI), other wound complications including seroma/hematoma, length of hospital stay, pain reported at follow-up appointment, and hernia recurrence.

RESULTS

Post-operative pain, surgical site infections and seromas did not differ between the totally laparoscopic and hybrid approach. The recurrence rates were 5.8% and 6.8% for the laparoscopic and hybrid group, respectively, which were not significantly different. The time to recurrence was 15 months (range 8-12) in the laparoscopic group and 7 months (range 6-36) in the hybrid group, also not significantly different. The hernia defect size and BMI were significantly higher in the hybrid group, without increased wound complications.

CONCLUSION

These results suggest that a hybrid approach to incisional ventral hernia repair with open defect closure is comparable to a totally laparoscopic closure. The hybrid technique can help facilitate fascial closure and resection of the hernia sac in patients with higher BMI and hernia defects up to 6 cm.

Robotic versus hybrid assisted ventral hernia repair: a prospective one-year comparative study of clinical outcomes

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) may be associated with chronic pain, seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence and poor quality of life (QoL). Our study evaluates whether robotic-assisted ventral hernia repair (rVHR) diminishes these complications compared to LVHR with primary closure of the defect (hybrid).

METHODS

Thirty-eight consecutive patients undergoing incisional ventral hernia operation with fascial defect size from 3 to 6 cm were recruited between November 2019 and October 2020. Nineteen patients underwent rVHR and nineteen underwent hybrid operation. The main outcome measure was postoperative pain, evaluated with a visual analogue scale (VAS: 0-10) at 1-month and at 1-year. Hernia recurrence was evaluated with ultrasound examination and QoL using the generic SF-36 short form questionnaire.

RESULTS

At the 1-month control visit, VAS scores were significantly lower in the rVHR group; 2.5 in the hybrid group and 0.3 in the rVHR group (p < 0.001). At the 1-year control, the difference in VAS scores was still significant, 2.8 vs 0.1 (p = 0.023). There was one hernia recurrence in the hybrid group (p = 0.331). QoL did not differ significantly between the study groups when compared to preoperative physical status at 1-year follow-up (p = 0.121). However, emotional status (p = 0.049) and social functioning (p = 0.039) improved significantly in the rVHR group.

CONCLUSIONS

Robotic-assisted ventral hernia repair (rVHR) was less painful compared to hybrid repair at 1-month and at 1-year follow-up. In addition, improvement in social functioning status was reported with rVHR.

TRIAL REGISTRATION ID

5200658.

Open versus robotic-assisted laparoscopic posterior component separation in complex abdominal wall repair

BACKGROUND

Transversus abdominis release (TAR) is a surgical technique used in the treatment of complex ventral hernias. The aim of this study was to compare outcomes of open (oTAR) versus robotic-assisted (rTAR) posterior component separation by TAR.

METHODS

Consecutive patients at two European hernia centres who underwent bilateral TAR were included. The primary endpoint was the duration of postoperative hospital stay.

RESULTS

Data from 90 rTAR and 79 oTAR operations were evaluated. Patient demographics were similar between groups in terms of age, sex, BMI, and co-morbidities. There were more smokers, and hernias were larger in the oTAR group (width 8.7 cm versus 10.0 cm; P = 0.031, length 11.6 cm versus 14.1 cm; P = 0.005). Duration of postoperative hospital stay was significantly shorter in the rTAR group (3.4 days versus 6.9 days; P < 0.001). Short-term serious complications (Clavien-Dindo grade III and above) were more frequent (20.3 per cent versus 7.8 per cent; P = 0.018), and there were more surgical site infections (12.7 per cent versus 3.3 per cent; P = 0.010) in the oTAR group. During a median follow-up of 19 months in the rTAR group and 43 months in the oTAR group, reoperation (4.4 per cent versus 8.9 per cent; P = 0.245), and recurrence rates (5.6 per cent versus 5.1 per cent; P > 0.009) were similar.

CONCLUSION

Patients with ventral incisional hernias who undergo bilateral rTAR had significantly shorter postoperative hospital stays and fewer short-term complications compared with patients undergoing bilateral oTAR.

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial

BACKGROUND

There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life.

METHOD

This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes.

RESULTS

Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective.

CONCLUSION

eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.

Reading a preoperative CT scan to guide complex abdominal wall reconstructive surgery

Computed tomography (CT) scanning is the imaging modality of choice when planning the overall management and operative approach to complex abdominal wall hernias. Despite its availability and well-recognised benefits there are no guidelines or recommendations regarding how best to read or report such scans for this application. In this paper we aim to outline an approach to interpreting preoperative CT scans in abdominal wall reconstruction (AWR). This approach breaks up the interpretive process into 4 steps-concentrating on the hernia or hernias, any complicating features of the hernia(s), the surrounding soft tissues and the abdominopelvic cavity as a whole-and was developed as a distillation of the authors' collective experience. We describe the key features that should be looked for at each of the four steps and the rationale for their inclusion.

Fascial defect closure versus bridged repair in laparoscopic ventral hernia mesh repair: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Several studies have examined effectiveness of primary fascial defect closure (FDC) versus bridged repair (no-FDC) during laparoscopic ventral hernia mesh repair (LVHMR). The purpose of this study was to systematically review and meta-analyse randomized controlled trials (RCTs) which compared safety and effectiveness of two techniques.

METHODS

Systematic literature searches (EMBASE, MEDLINE, PubMed, and CINAHL) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines using predefined terms. RCTs comparing FDC and no-FDC in LVHMR were identified and retrieved. Primary outcomes were risk of recurrence and risk of major complications analyzed as a single composite outcome. Secondary outcomes were risks of seroma formation, clinical or radiologically confirmed eventration, incidence of readmission to hospital, postoperative changes in quality of life (QoL), and postoperative pain. Random effects modeling to summarize statistics were performed. The risk of bias was assessed using Cohrane's Risk of Bias tool 2.

RESULTS

Three RCTs that enrolled total of 259 patients were included. There was clinical heterogeneity present between studies related to patients' characteristics, hernia characteristics, and operative techniques. There was no difference found in primary outcomes, risks of seroma formation, eventration, and chronic pain. There is conflicting evidence on how both techniques affect postoperative QoL or early postoperative pain.

CONCLUSIONS

Both techniques were detected to have equal safety profile and do not differ in risk of recurrence, seroma formation, risks of clinical or radiological eventration. Giving uncertainty and clinical equipoise, another RCT examining FDC vs no-FDC laparoscopic mesh repair separately for primary and secondary hernias using narrow inclusion criteria for hernia size on well-defined population would be ethical and pragmatic.

PROSPERO REGISTRATION

CRD42021274581.

Outcomes of posterior component separation with transversus abdominis release (TAR) in large and other complex ventral hernias: a single-surgeon experience

PURPOSE

Over the last years, great advances in the repair of abdominal wall hernias have dramatically improved patients' outcomes. Especially for large and other complex ventral hernias, the application of component separation techniques has been a landmark in their successful management. The aim of this study is to present our experience with the posterior component separation with transversus abdominis release (TAR) in patients with these demanding ventral hernias.

METHODS

A retrospective analysis of prospectively collected data of all patients who underwent elective ventral hernia repair with TAR between January 2016 and December 2019 was performed. Preoperative, intraoperative, and postoperative data were analyzed.

RESULTS

A total of 125 patients with large and other complex ventral hernias were included in the final analysis. More than 80% of patients had one or more comorbidities. Of all patients, 116 (92.8%) had a history of previous abdominal surgery, 27 (21.6%) had a history of SSI and nine (7.2%) had active fistulas. Postoperatively, SSOs were presented in 11 patients (8.8%), including three cases of SSI. Neither mesh infection occurred, nor mesh excision required. With a mean follow-up of 2.5 years, only one recurrence was observed.

CONCLUSIONS

With a wound complication rate of less than 9% and a recurrence rate of less than 1%, our results show that TAR is a reliable, safe and effective technique for the repair of massive and other complex ventral hernias. The combination of knowledge of the abdominal wall anatomy at a proficient level, proper training, and adoption of a strict prehabilitation program are considered prerequisites for the successful management of such demanding hernias.

A Study of Intraperitoneal Onlay Mesh Repair Using Barbed Sutures for Abdominal Incisional Hernia

Objective

We investigated the validity of our intraperitoneal onlay mesh (IPOM) Plus technique with barbed sutures.

Background

Laparoscopic intraperitoneal onlay mesh repair has become a proven method for treating abdominal incisional hernias in recent years. There have been a few reports on the utility of IPOM Plus, which is IPOM + celiorrhaphy, although this method has not been widely discussed. We adopted the IPOM Plus technique with barbed sutures at our hospital and investigated the validity of this technique.

Methods

We included 7 patients who underwent IPOM Plus repair from 2015 to 2017 at our hospital. We excluded patients with a hernia hilum &lt;2 cm or ≥10 cm, age &lt; 20 years old, PS3 or more, and uncontrolled comorbidity. The hernial orifice was closed laparoscopically using barbed sutures and subsequently secured by tacking on an onlay mesh.

Results

The median hernial orifice size of the 7 patients was 45 mm (25 to 55 mm). Hernia onset occurred after laparotomy in all cases. In one case, an abdominal incisional hernia recurred after IPOM used to treat the condition 15 years earlier. The mean duration of surgery was 80.5 minutes (53 to 126 minutes), and the median pain scale score was 3 points (0 to 3 points), indicating little pain. None of the patients reported persistent postoperative pain. The mean duration of the postoperative hospital stay was a median of 3.5 days (2 to 5 days). Both short- and long-term outcomes indicated that no recurrence or complications, such as bulging or seroma, occurred.

Conclusions

IPOM Plus with intracavitary abdominal suturing using barbed suture for abdominal scar hernia repair may be a valid surgical procedure.

Endoscopic retromuscular technique (eTEP) vs conventional laparoscopic ventral or incisional hernia repair with defect closure (IPOM +) for midline hernias. A case-control study

PURPOSE

This study aimed at clinical results in terms of postoperative pain and functional recovery of new technique (eTEP) compared to IPOM + for ventral/incisional midline hernias. Recurrence rate, intra/postoperative complications and aesthetic results are secondary aims.

METHODS

Data from consecutive patients requiring minimally invasive hernia repair were collected. From January 2015 to September 2018, patients with midline ventral/incisional hernias underwent IPOM + were compared to patients underwent eTEP procedure from October 2018 to December 2019 in a case/control study.

RESULTS

Thirty-nine patients in IPOM + group and 40 in eTEP group were included. No significant differences were identified when hernias types, mean defect area, mean mesh area and intraoperative/postoperative complications (except seroma rate in favor of eTEP group) were compared. Operative time and hospital stay were significantly higher in eTEP group and IPOM + group, respectively. eTEP group showed significantly less pain on 1st, 7th and 30th postoperative days than IPOM + group. Restriction of activities was significantly decreased in eTEP group on the 30th and 180th day after surgery. Significant differences were observed in terms of cosmetic results 30th and 180th days after surgery in favor of eTEP group. Average follow-up was 15 months in eTEP group and 28 months in IPOM + group. No recurrences were identified in eTEP group and one recurrence in IPOM + group with no significant differences.

CONCLUSION

Endoscopic retromuscular technique shows significant lower postoperative pain, better functional recovery and cosmesis than IPOM + without differences in intra/postoperative complications (except seroma rate) or recurrences during the follow-up. eTEP requires longer operative time.

Results of a Prospective Cohort Study on Open Rives Technique of the Midline Incisional Hernia: Midline Closure and Mesh Overlap

Background. Rives repair has been traditionally used for large abdominal wall defects with good results on terms of recurrence. However, it is limited by the lateral border of the posterior rectus sheath. The objective of our study was to evaluate recurrence rate, midline closure and mesh overlap in patients operated on elective midline incisional hernia by open Rives retromuscular repair. Methods. This is a prospective observational study of 83 patients who underwent elective open Rives technique between January 2014 and December 2018. Main inclusion criteria were adults with a midline incisional hernia. Recurrence, midline closure and mesh overlap were determined. Results. At a median postoperative follow-up of 32 (5-59) months, 8 cases of recurrence were reported. Patients with recurrence had wider hernia defects (101 ± 52 mm vs 66 ± 36 mm, P = .014) and were repaired with wider meshes (191 ± 93 mm vs 137 ± 68 mm, P = .042). However, although it was not statistically significant, midline closure was lower (38% vs 59%), as well as the overlapping relationship between mesh area and hernia defect area (2.937:1 vs 3.732:1) on patients that developed a recurrence. Conclusions. Rives technique provides good mid-term results in a midline incisional hernia (10% of recurrence at 36 months), including wider hernias in the recurrent cohort. The authors believe that other techniques which allow midline closure and placement of bigger meshes should be considered, especially in those hernias classified as W3 on EuraHS classification (more than 10 cm on width size).