Laparoscopic versus open incisional and ventral hernia repair: a systematic review and meta-analysis

Laparoscopic versus open mesh repairs for small-sized ventral and incisional hernias: a propensity score analysis of a retrospective cohort of patients

INTRODUCTION

For ventral/incisional hernias between 1 and 4 cm, there is still controversy regarding open or laparoscopic mesh repairs. The study evaluated via a propensity-score adjusted analysis, the differences in outcomes between a laparoscopic and open ventral hernia mesh repair.

METHODOLOGY

A single institution retrospective cohort study was performed. All patients with a ventral or incisional hernia between 1 and ≤ 4 cm, with a mesh repair, were reviewed. A propensity-score adjusted analysis was performed to account for baseline differences. Subgroup analyses were also performed. Outcome measures included recurrence, chronic pain, complications, postoperative adhesive occurrences, length of stay and operative duration.

RESULTS

Over a 6-year period, 194 patients (91 laparoscopic; 103 open) were included. Mean follow-up duration and defect size were 8.0 months and 2.6 cm, respectively. Baseline differences in the univariate analysis between groups were adjusted for via propensity scoring. In the propensity-score adjusted analysis, a laparoscopic mesh repair was significantly associated with a lower likelihood of postoperative adhesive occurrences, with no differences in recurrence, chronic pain, complications, length of stay and operative duration. This association remained for hernia defects down to ≤ 3 cm. There were no significant differences between the laparoscopic and open groups when stratified for hernia defects of 1-2 cm. For the subgroup analysis, in contrast to an intraperitoneal on-lay mesh placement, open on-lay mesh placement was associated with a higher likelihood of postoperative adhesive occurrences.

CONCLUSION

For patients with small-sized ventral/incisional hernias between 1 and 4 cm, laparoscopic mesh repairs may be associated with reduced postoperative adhesive occurrences, with no difference in other outcomes.

Short-term outcomes of mesh-suture repair in the treatment of ventral hernias: a single-center study

BACKGROUND

Defect closure with mesh suture is a novel technique for hernia repair. Originally described as the construction of lightweight macroporous polypropylene mesh strips as a suture material, it is now available as an FDA-approved product. Mesh suture better distributes tensile forces and reduces fascial tearing compared to traditional suture but requires less implanted material and tissue dissection compared to planar mesh. Limited studies have demonstrated mesh suture's effectiveness in short-term recurrence rates. This study describes the short-term outcomes of our initial experience with mesh-suture-based herniorrhaphy.

METHODS

This study is an IRB-approved, single-center, retrospective review of surgeon case logs from May 2023 to February 2024. All patients who had undergone hernia repair utilizing mesh suture (Duramesh, Mesh Suture Inc, Chicago, IL) as the method of repair at our medical center were enrolled. A descriptive analysis regarding patient and hernia characteristics was performed and short-term outcomes were analyzed.

RESULTS

We identified 63 patients (Mean age 61, Mean BMI 31.0 kg/m2, 60% female) who had undergone mesh-suture repair since its availability at our institution. Hernias included 31.7% primary, 27.0% incisional, 34.9% parastomal, and 6.4% other. Of these, 8 (12.7%) were recurrent hernia repairs. The average defect size was 41.0 cm2, with a range from 0.25 to 459 cm2. Average length of stay was 3.2 days, with a range of 0 to 20. Eleven patients (17.5%) were readmitted in the 90-day postoperative period. With an average follow-up of 45 days, there were ten surgical site occurrences (including four surgical site infections) and three recurrences (4.8%).

CONCLUSIONS

Our initial experience with mesh-suture herniorrhaphy has demonstrated acceptable short-term rates of surgical site occurrences and recurrences. This provides additional support for its use, particularly in patients where a planar mesh-based repair might traditionally be avoided. Further studies of mesh-suture herniorrhaphy long-term recurrence rates and cost-effectiveness are needed.

Minimally invasive intraperitoneal onlay mesh plus (IPOM +) repair versus enhanced-view totally extraperitoneal (e-TEP) repair for ventral hernias: a systematic review and meta-analysis

INTRODUCTION

Following concerns regarding an intraperitoneal mesh, newer ventral hernia repair (VHR) approaches focus on placing the mesh outside of the peritoneal cavity. The e-TEP technique used the retromuscular space and is suggested to be associated with decreased postoperative pain compared to IPOM +. This study aims to compare the IPOM + with the e-TEP for VHR.

METHODS AND PROCEDURES

We searched for studies comparing endoscopic IPOM + and e-TEP in PubMed, EMBASE, and Cochrane databases from inception until September 2023. Outcomes were Visual Analog Scale (VAS) after 24 h of surgery and between 7 and 10 days after surgery, operative time, length of stay (LOS), seroma, recurrence, and readmission. RStudio was used for statistical analysis. Heterogeneity was assessed with I2 statistics, with random effect for I2 > 25%.

RESULTS

From 149 records, 7 were included, from which 3 were RCTs, 3 were retrospective studies, and 1 was an observational prospective study. 521 patients were included (47% received e-TEP and 53% received IPOM +). 1 study included only robotic surgeries and 6 studies included only laparoscopy. Mean defect width was 3.62 cm ± 0.9 in the e-TEP group and 3.56 cm ± 0.9 in the IPOM + group. IPOM + had higher VAS after 1 day of surgery (MD - 3.35; 95% CI - 6.44; - 0.27; P = 0.033; I2 = 99%) and between 7 and 10 days after surgery (MD - 3.3; 95% CI - 5.33, - 1.28; P = 0.001; I2 = 99%). e-TEP repair showed with longer operative time (MD 52.89 min; 95% CI 29.74-76.05; P < 0.001; I2 = 92%). No differences were seen regarding LOS, seroma, recurrence, and readmission.

CONCLUSION

The e-TEP repair is associated with lower short-term postoperative pain after VHR compared to IPOM +, but with longer operative time. More RCTs are required to assess these results with long-term follow-up and determine its role in the armamentarium of the abdominal wall surgeon.

Comparative analysis of laparoscopic, retro-muscular, and open mesh repair techniques for ventral and incisional hernias: a comprehensive review and meta-analysis

Ventral hernias are abnormalities in anterior abdominal wall occurring due to an incision or are congenital. This comprehensive review and meta-analysis aim to objectively compare laparoscopic to retro-muscular or any other mesh repair approach to manage ventral incisional hernia. To identify studies that managed ventral incisional hernia using laparoscopic, open, or retro-muscular mesh repair techniques, a comprehensive literature search was performed. Random effects model was used, and data were presented as log odds ratio (logOR) or as Hedge's g with corresponding 95% confidence intervals (CI). Cochran's Q test was implemented to measure heterogeneity among articles, and funnel plots were utilized to examine publication bias visually. Quality of all selected studies was assessed using Critical Appraisal Checklists for Studies developed by the Joanna Briggs Institute. 20 studies (16,247 patients) were included published from 2003 to 2023. Significantly reduced incisional hernias developed in laparoscopic group. The recurrence of hernia lowered with laparoscopic repair vs. open repair. In retro-muscular vs. laparoscopic, recurrence was lower, however, not statistically significant (p = 0.97). Open repair type resulted in a longer hospital stay than laparoscopic (p = 0.03). In laparoscopic repair, the postoperative complications reduced compared to the open repair (p = 0.02). Laparoscopic incisional and ventral hernia repair is a practical and successful alternative to open method. It is associated with shorter hospital stay and lower risk of postoperative complications. In few instances, retro-muscular mesh repair may be opted for.

The Enhanced-View Totally Extraperitoneal Repair for Ventral and Incisional Hernia: Midterm Results of an Evolving Technique

Introduction: In the field of abdominal wall hernias, several innovative procedures have been developed, including the extended/enhanced-view totally extraperitoneal (eTEP) hernia repair technique. Initially introduced for laparoscopic hernia repair by J. Daes, it was subsequently applied to ventral hernia repair (VHR) and incisional hernia repair (IVHR) by I. Belyansky et al. This article presents the midterm experience and outcomes of our center's experience with the endoscopic technique based on the principles of eTEP during IVHR and VHR. Method: A review was conducted of a prospectively collected database of abdominal wall hernia. Patients who underwent eTEP VHR or IVHR between October 2018 and February 2021 were identified. Results: A total of 51 patients underwent an eTEP-RS or eTEP-TAR procedure, with a 24-month follow-up period. Of the 51 patients included in the study, 43 underwent eTEP-RS treatment, while 8 required an additional transversus abdominis release (3 unilaterally). One patient developed a large hematoma necessitating reoperation and drainage via the eTEP approach. Seven patients developed seromas, which were treated conservatively, while 2 patients experienced surgical site infections, which were managed with a single-use negative pressure wound therapy system. Two patients exhibited recurrence at sites above the epigastric edge of the mesh. Conclusion: Moreover, the advancement of minimally invasive surgical techniques for abdominal wall reconstruction has rendered the eTEP approach a viable option for both primary and incisional VHR, with promising midterm 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.

A Clinical Study of Anterior Abdominal Wall Hernias and Its Management: A Medical College Experience

Objective We aim to evaluate the various risk factors contributing to the occurrence of anterior abdominal wall hernias and assess the various surgical modalities. Materials and methods This prospective observational research was conducted between 2022 and 2024 at a tertiary care health center, involving 100 participants with an anterior abdominal wall hernia diagnosis aged over 14 years. The study excluded patients under 14 years with bleeding diathesis, inherited coagulopathies, inguinal or femoral hernias, or recurrent ventral hernias. Participants underwent detailed clinical examinations and biochemical evaluations and underwent a primary ultrasonography (USG)/contrast-enhanced computed tomography (CECT) to determine defect size. Risk factors were documented, including age, gender, occupation, body mass index (BMI), comorbidities, previous surgery history, multiparity, smoking, chronic straining due to constipation or benign prostatic hyperplasia (BPH), malnutrition, chronic steroid use, chronic renal failure, and chronic liver disease. The surgical procedure was determined by the same surgical team for all cases. Standard antibiotic prophylaxis and preoperative painting/draping protocols were followed in all cases. Intraoperatively, intraoperative time (in hours) was documented. Postoperative parameters included pain, hematoma formation, seroma formation, surgical site infections (SSIs), and early recurrence. These intra- and postoperative findings constituted the primary outcome parameters. Secondary outcome parameters included hospital stay duration and time taken to return to work. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 16 (IBM SPSS Statistics, Armonk, NY) software. Results The study analyzed the occurrence of ventral hernias in 100 patients, with the fourth decade having the highest occurrence (n=42 (42%)). The majority of the participants were male (female: n=47 (47%), male: n=53 (53%)). The majority of the participants were laborers, and 24% (n=24) were office workers. The study found that hypertension, diabetes mellitus, and chronic obstructive pulmonary disease were risk factors for hernias. Other risk factors included obesity, previous history of surgery, multiparity, smoking, chronic straining, malnutrition, and chronic steroid use. The most common type of ventral hernia was umbilical hernia (n=33 (33%)), followed by paraumbilical hernias (n=30 (30%)), and incisional hernias (n=20 (20%)). Of the 100 patients, 74% underwent open hernia repair, with the mean operation time being minimal in cases managed with laparoscopic repair (2.5±0.67 hours). Postoperative pain was highest with the Rives-Stoppa (RS) repair with component separation group. The incidence of surgical site infection was the maximum among cases of open anatomical repair (41.7%), followed by RS repair (31.3%), while it was the minimum in laparoscopic repair (3.7%). Early recurrence was lower in the laparoscopic group (n=1 (3.7%)). Conclusion The study highlights risk factors for abdominal wall hernia and management approaches. Understanding these is crucial for identifying and preventing recurrence. Surgeons must choose the right surgical approach based on patient health and symptoms to achieve desired outcomes and minimize complications. In addition, surgical expertise, availability of resources, and knowledge of what works best for the surgeon constitute important determinants of surgical outcomes.

Hybrid Technique for Abdominal Wall Hernia Repair: Description and Early Results

Objective Ventral hernia repair is a widely practiced surgical procedure worldwide. The objective of this paper is to evaluate and analyze the results of a hybrid approach for treating ventral hernias. Methods All patients with clinically and radiologically proven ventral hernia underwent hybrid laparoscopic ventral hernia repair at Princess Royal University Hospital, London, United Kingdom using a retrospective approach with the same surgical team. Large defects >10 cm, inguinal hernia, para-stomal hernia, incarcerated patients, and spigelian hernia were excluded. We utilized the laparoscopic approach for the dissection and isolation of the sac and used the port site for the delivery of mesh into the abdominal cavity. Results Our study comprises 67 patients, with 39 males (58.2%) and 28 females (41.8%). The median age in our study group was 41 years (range: 18-65 years). The median BMI was 38 kg/m2 (range: 24-52 kg/m2). The majority of the cases were umbilical or paraumbilical hernias (n = 46). The median defect size in our study was 5.4 cm (range: 2-10 cm). The median operative time was 67 minutes. We have not encountered any recurrences in this group. Conclusion This hybrid approach combines the advantages of both the open and laparoscopic approaches.

Evaluation of the Erector spinae plane block for postoperative analgesia in laparoscopic ventral hernia repair: a randomized placebo controlled trial

BACKGROUND

The Erector spinae plane block (ESPB) reduces postoperative pain after several types of abdominal laparoscopic surgeries. There is sparse data on the effect of ESPB in laparoscopic ventral hernia repair. The purpose of this study was to test the postoperative analgesic efficacy of an ESPB for this procedure.

METHODS

In this prospective, double-blind, randomized controlled study, adult patients undergoing laparoscopic ventral hernia repair were randomly assigned to either bilateral preoperative ESPB with catheters at the level of Th7 (2 × 30 ml of either 2.5 mg/ml ropivacaine or saline), with postoperative catheter top ups every 6 h for 24 h. The primary outcome was rescue opioid consumption during the first hour postoperatively. Secondary outcomes were total opioid consumption at 4 h and 24 h, pain scores, nausea, sedation, as well as Quality of Recovery 15 (QoR-15) and the EuroQol-5 Dimensions (EQ-5D-5L) during the first week.

RESULTS

In total, 64 patients were included in the primary outcome measure. There was no significant difference in rescue opioid consumption (oral morphine equivalents (OME)) at one hour postoperatively, with the ESPB group 26.9 ± 17.1 mg versus 32.4 ± 24.3 mg (mean ± SD) in the placebo group (p= 0.27). There were no significant differences concerning the secondary outcomes during the seven-day observation period. Seven patients received a rescue block postoperatively, providing analgesia in five patients.

CONCLUSION

We found no difference in measured outcomes between ESPB and placebo in laparoscopic ventral hernia repair. Future studies may evaluate whether a block performed using higher concentration and/or at a different thoracic level provides more analgesic efficacy.

TRIAL REGISTRATION

NCT04438369 ; 18/06/2020. .

Laparoscopic Intraperitoneal Onlay Mesh (IPOM) in the Treatment of Ventral Hernias: Technique Discussion Points

Incisional ventral hernias (IVH) are a common occurrence worldwide. The resolve is fundamentally surgical. In this regard, laparoscopic treatment has become the standard. This paper aims to review intraperitoneal onlay mesh (IPOM) as a surgical solution for IVH and to explore the limitations and advantages in relation to the technique of mesh fixation, defect suture, seroma formation, and recurrence in accordance with the data published. The article is structured as a narrative review and relies on the Scale for the Assessment of Narrative Review Articles (SANRA) convention. In the analysis, we included articles published in the literature regarding the surgical treatment of ventral hernias (umbilical and incisional) through the IPOM technique. We explored data regarding the mesh fixation technique on the anterior abdominal wall (tacks or sutures), indications and limitations of defect closure, incidence of seroma formation, and recurrence rate. Laparoscopic IPOM is a better option for IVH up to 10 cm than the open technique with regard to aesthetics, length of hospital stay, and postoperative pain. There is no difference in recurrence rates. Suturing of the defect should be done to decrease seroma formation and maintain the functionality of the abdominal wall. Ideally, the suture should be done intraperitoneally or laparoscopically. Regarding pain in mesh fixation, there seems to be an increase in the short-term postoperative pain in the suture groups, but at six months, when compared to the tacks groups, there is no difference. New methods are being developed that include different types of glue but require large prospective, randomized trials if they are to be included in the guidelines.

Comparison between the open and the laparoscopic approach in the primary ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

Ventral hernia repair underwent various developments in the previous decade. Laparoscopic primary ventral hernia repair may be an alternative to open repair since it prevents large abdominal incisions. However, whether laparoscopy improves clinical outcomes has not been systematically assessed.

OBJECTIVES

The aim is to compare the clinical outcomes of the laparoscopic versus open approach of primary ventral hernias.

METHODS

A systematic search of MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted in February 2023. All randomized controlled trials comparing laparoscopy with the open approach in patients with a primary ventral hernia were included. A fixed-effects meta-analysis of risk ratios was performed for hernia recurrence, local infection, wound dehiscence, and local seroma. Meta-analysis for weighted mean differences was performed for postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

RESULTS

Nine studies were included in the systematic review and meta-analysis. The overall hernia recurrence was twice less likely to occur in laparoscopy (RR = 0.49; 95%CI = 0.32-0.74; p < 0.001; I2 = 29%). Local infection (RR = 0.30; 95%CI = 0.19-0.49; p < 0.001; I2 = 0%), wound dehiscence (RR = 0.08; 95%CI = 0.02-0.32; p < 0.001; I2 = 0%), and local seroma (RR = 0.34; 95%CI = 0.19-0.59; p < 0.001; I2 = 14%) were also significantly less likely in patients undergoing laparoscopy. Severe heterogeneity was obtained when pooling data on postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

CONCLUSION

The results of available studies are controversial and have a high risk of bias, small sample sizes, and no well-defined protocols. However, the laparoscopic approach seems associated with a lower frequency of hernia recurrence, local infection, wound dehiscence, and local seroma.

Short-term outcomes after open versus robot-assisted repair of ventral hernias: a nationwide database study

PURPOSE

The robotic platform is widely implemented; however, evidence evaluating outcomes of robotic ventral hernia repair is still lacking. The aim of the study was to evaluate the short-term outcomes after open and robot-assisted repair of primary ventral and incisional hernias.

METHODS

Nationwide register-based cohort study with data from the Danish Ventral Hernia Database and the National Danish Patients Registry was from January 1, 2017 to August 22, 2022. Robot-assisted ventral hernia repairs were propensity score matched 1:3 with open repairs according to the confounding variables defect size, Charlson comorbidity index score, and age. Logistic regression analyses were performed for factors associated with length of stay > 2 days, readmission, and reoperation within 90 days.

RESULTS

A total of 528 and 1521 patients underwent robot-assisted and open repair, respectively. The mean length of hospital stay in days was 0.5 versus 2.1 for robot-assisted and open approach, respectively (P < 0.001) and open approach was correlated with risk of length of stay > 2 days (OR 23.25, CI 13.80-39.17, P < 0.001). The incidence of readmission within 90 days of discharge was significantly lower after robot-assisted repair compared to open approach (6.2% vs. 12.1%, P < 0.001). Open approach was independently associated with increased risk of readmission (OR 21.43, CI 13.28-39.17, P = 0.005, P < 0.001).

CONCLUSION

Robot-assisted ventral hernia repair is safe and feasible and associated with shorter length of stay and decreased risk of readmission compared with open ventral hernia repair.

Robotic approach for retromuscular ventral hernia repair may be associated with improved wound morbidity in high-risk patients: a propensity score analysis

BACKGROUND

Retromuscular sublay (RMS) technique for repair of ventral hernias has gained popularity due to lower risk of recurrence and wound complications. Robotic approaches to RMS have been shown to decrease hospital stay; however, previous studies have failed to show a significant reduction in wound morbidity. Utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database, this study sought to determine the effect of robotic approach on wound morbidity, while specifically focusing on a high-risk population.

METHODS

A retrospective review of elective robotic and open RMS repairs in the ACHQC database was performed. Patients deemed to be high-risk for wound complications were included: adult patients with BMI greater than 35 and who were either current smokers or diabetics. A propensity score match was then done to balance covariates between the two groups. Main outcomes of concern were surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrence requiring procedural intervention (SSOPI) at 30-day follow-up.

RESULTS

A total of 917 patients met inclusion criteria. After propensity score matching, 211 patients matched for each approach. There was no difference in overall SSO (18% for Open vs 23% for Robotic, p = 0.23). Open repair was associated with higher rates of SSI (4% vs 1%, p = 0.032) and SSOPI (9% SSOPI vs 3%, p < 0. 015). As seen in previous studies, there was a higher rate of seroma associated with Robotic RMS repair (87% vs 48%, p < 0.001) in patients that developed an SSO.

CONCLUSIONS

In this analysis, a robotic approach was associated with decreased rates of SSI and SSOPI in obese patients who were either current smokers or diabetics. In effort to reduce wound morbidity and the associated physical and economic costs, robotic approach for retromuscular ventral hernia repair should be considered in this patient population.

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.

Investigation of optimal hernia repair techniques in patients with inflammatory bowel disease

INTRODUCTION

Multiple laparotomies, immunosuppressive therapy, wound infection, and malnutrition are risk factors for incisional hernia development, which places inflammatory bowel disease (IBD) patients at high risk. With advances in minimally invasive techniques, this study assesses incisional hernia repair techniques and complications in the IBD population.

METHODS

A single-center, retrospective review of adults with IBD who underwent incisional hernia repair from 2008 to 2022. Complications relative to operative approach and mesh placement location were assessed using descriptive and univariate statistics.

RESULTS

Eighty-eight IBD patients underwent incisional hernia repair. Fifty-two (59.1%) were on immunomodulators and 30 (34.1%) were repaired primarily. Thirty-five (39.7%) hernias recurred, of whom 19 (33%) had mesh placed. Three (30%) occurred in onlay repairs and 16 (33%) occurred in underlay repairs. Subdivision of underlay repairs into intraperitoneal, preperitoneal and retrorectus mesh placement revealed recurrence rates of 35.1%, 50%, and 14.3%, respectively. Patients with open repair were more likely to have intraoperative bowel injury (28.6% vs 9.7%, p = 0.041) and develop postoperative seromas/abscesses (12.5% vs 0%, p = 0.001) and wound complications (17.9% vs 0%, p = 0.012) compared to laparoscopic. Seromas/abscesses developed more frequently in onlay repairs compared to underlay (40% vs 2.13%, p = 0.001). Twelve (13.6%) patients presented with postoperative small bowel obstruction (SBO), 7 (58.3%) of whom had mesh placed, and 6 (85.7%) were underlay. All SBO after underlay repair had intraperitoneally placed mesh. When comparing surgeons, hernias were more likely to recur performed by colorectal surgeons compared to hernia surgeons (63.3% vs 21.3%, p < 0.001).

CONCLUSION

In IBD patients, minimally invasive approaches lead to fewer perioperative complications compared to open. Underlay mesh placement demonstrated decreased incidence of seroma/abscess formation compared to onlay. When sub-grouped, underlay placements were similar in terms of complications. Retrorectus placement, however, had fewer recurrences and no readmissions for SBO. This suggests a minimally invasive approach or placement of retrorectus mesh may provide the optimal repair in this patient population.

Outcomes after ventral hernia repair using the extended totally extraperitoneal approach: Initial experience from the Philippines

INTRODUCTION

Newer extraperitoneal techniques of laparoscopic ventral/incisional hernia repair (LVIHR) have been continually introduced since the popularity of the laparoscopic intraperitoneal onlay mesh technique began in 1993. One of which is the extended totally extraperitoneal (eTEP) approach allowing wide mesh augmentation, concurrent repair of diastasis recti, and performance of transversus abdominis release (TAR) for large/complex hernias. However, minimally invasive/laparoendoscopic ventral hernia repair is not yet widely adopted in the Philippines. We aim to share our preliminary experience with LVIHR using the eTEP approach.

METHODS

This was a retrospective review of all consecutive eTEP repairs for ventral hernia between January 2019 and September 2023. The clinical profiles of all patients were gathered. Hernia characteristics, operative profile, and postoperative outcomes were reported.

RESULTS

Thirty-five patients were included in the study with a mean age of 54.7; 60% were incisional hernias, and the most common hernia location was the umbilical area. A defect size between 4 and 10 cm was reported in 54.3%. eTEP-TAR was necessary in 12 patients. At a median follow-up of 16 months, two patients developed seroma, one hematoma, and two surgical site infections. All were successfully managed conservatively. Only one patient developed recurrence.

CONCLUSION

eTEP approach is safe and feasible for repairing ventral hernias. Our preliminary experience showed acceptable outcomes similar to the published literature. Surgeons interested in this technique should be familiar with the abdominal wall anatomy, carefully select patients during preoperative planning, and undergo mentorship with hernia surgeons experienced with the technique to shorten the learning curve.

The INCH-trial: a multicenter randomized controlled trial comparing short- and long-term outcomes of open and laparoscopic surgery for incisional hernia repair

BACKGROUND

Laparoscopic incisional hernia repair is increasingly performed worldwide and expected to be superior to conventional open repair regarding hospital stay and quality of life (QoL). The INCisional Hernia-Trial was designed to test this hypothesis.

METHODS

A multicenter parallel randomized controlled open-label trial with a superiority design was conducted in six hospitals in the Netherlands. Patients with primary or recurrent incisional hernias were randomized by computer-guided block-randomization to undergo either conventional open or laparoscopic repair. Primary endpoint was postoperative length of hospital stay in days. Secondary endpoints included QoL, complications, and recurrences. Patients were followed up for at least 5 years.

RESULTS

Hundred-and-two patients were recruited and randomized. In total, 88 patients underwent surgery and were included in the intention-to-treat analysis (44 in the open group, 44 in the laparoscopic group). Mean age was 59.5 years, gender division was equal, and BMI was 28.8 kg/m. The trial was concluded early for futility after an unplanned interim analysis, which showed that the hypothesis needed to be rejected. There was no difference in primary outcome: length of hospital stay was 3 (range 1-36) days in the open group and 3 (range 1-12) days in the laparoscopic group (p = 0.481). There were no significant between-group differences in QoL questionnaires on the short and long term. Satisfaction was impaired in the open group. Overall recurrence rate was 19%, of which 16% in the open and 23% in the laparoscopic group (p = 0.25) at a mean follow-up of 6.6 years.

CONCLUSIONS

In a randomized controlled trial, short- and long-term outcomes after laparoscopic incisional hernia repair were not superior to open surgery. The persisting high recurrence rates, reduced QoL, and suboptimal satisfaction warrant the need for patient's expectation management in the preoperative process and individualized surgical management.

TRIAL REGISTRATION

Netherlands Trial Register NTR2808.

MINIMALLY INVASIVE SURGICAL REPAIR FOR ABDOMINAL WALL HERNIAS IN NONHUMAN PRIMATES, TWO CASES IN WESTERN LOWLAND GORILLAS (GORILLA GORILLA GORILLA)

A 33-yr-old female Western lowland gorilla (Gorilla gorilla gorilla) was diagnosed with a congenital umbilical hernia that was reducible and asymptomatic; change in the hernia was noted after parturition and concerns regarding increased risk of bowel incarceration developed. The hernia was successfully repaired with robot-assisted laparoscopic surgery. A 5-mon-old male Western lowland gorilla presented with bilateral inguinal hernias that were repaired via elective laparoscopic repair. In both cases, the gorillas did well without complications and never appeared to acknowledge wounds or exhibit signs of pain postoperatively. A literature review and interinstitutional survey was conducted to determine success rate of minimally invasive versus open repair of hernias in nonhuman primates (NHP). Of the cases identified, recurrence and/or wound morbidity was seen in 0% of laparoscopic repairs and 50% of open repairs. NHP may benefit from elective, minimally invasive surgical techniques that may reduce hernia recurrences and wound morbidity.

Primary Uncomplicated Ventral Hernia Repair: Guidelines and Practice Patterns for Routine Hernia Repairs

Surgical repair of primary umbilical and epigastric hernias are among the most common abdominal operations in the world. The hernia defects range from small (<1 cm) to large and complex even in the absence of prior incision or repair. Mesh has generally been shown to decrease recurrence rates, and its use and location of placement should be individualized for each patient. Open, laparoscopic, and robotic approaches provide unique considerations for the technical aspects of primary repair with or without mesh augmentation.

Evaluation of rectus abdominis muscle strength and width of hernia defect in patients undergoing incisional hernia surgery

BACKGROUND

The aim of this study was to analyze the strength status of the rectus abdominis muscle in patients with incisional hernia and the relationship between the width of the hernia defect and the strength of the rectus abdominis muscle.

METHODS

This is a observational cohort study of patients with medial line incisional hernia (July-October 2022), classified as W2 according to the European Hernia Society (EHS). The data collected were demographic and clinical characteristics related to hernia, and measure of the rectus abdominis muscle strength using an isokinetic dynamometer and a strain gauge. We analyzed the relationship between hernia width and rectus abdominis muscle strength with correlation tests to adjustment by age, sex, BMI, and body composition.

RESULTS

A total of 40 patients (64% female) with a mean age of 57.62 years (SD 11) were enrolled in the study. The mean BMI was 29.18 (SD 5.06), with a mean percentage of fat mass of 37.8% (SD 8.47) and a mean percentage of muscle mass of 60.33% (SD 6.43). The maximum width of the hernia defect was 6.59 cm (SD 1.54). In the male group, the mean bending force moment (ISOK_PT) was 94.01 Nw m (SD 34.58), bending force moment relative to body weight (ISOK_PT_Weight) was 103.32 Nw m (SD 37.48), and peak force (PK_90) was 184.71 N (SD 47.01). In the female group, these values were 58.11 Nw m (SD 29.41), 66.48 Nw m (SD 32.44), and 152.50 N (SD 48.49), respectively. Statistically significant differences were observed in the relationship between the data obtained with the isokinetic dynamometer and sex (p = 0.002), as well as between the data obtained with the isokinetic dynamometer and age (p = 0.006). Patients in the 90th percentile (P90) of rectus abdominis muscle strength also had smaller hernia defect widths (p = 0.048).

CONCLUSIONS

In this study, age and sex were identified as the most statistically significant predictor variables for rectus abdominis muscle strength. The width of the hernia defect exhibited a trend towards statistical significance.

A Comparative Study on Outcomes and Quality of Life Changes Following Ventral Transabdominal Preperitoneal (Ventral-TAPP) and Laparoscopic Intraperitoneal Onlay Mesh (IPOM)-Plus Repair for Ventral Hernia

Background Ventral transabdominal preperitoneal (ventral-TAPP) repair and intraperitoneal onlay mesh (IPOM) plus repair are two options among the available techniques of laparoscopic ventral hernia repair (LVHR). We conducted a comparative study to evaluate the clinical and quality of life (QoL)-related outcomes between ventral-TAPP and IPOM-plus repair. It was hypothesized that both procedures offered similar outcomes and QoL. Materials and methods The study included 32 consecutive patients undergoing LVHR, divided equally between ventral-TAPP and IPOM-plus groups. In the ventral-TAPP procedure, a peritoneal flap was created around the defect, followed by defect approximation and polypropylene mesh placement in the pre-peritoneal pocket. For the IPOM-plus procedure, the defect was closed and a composite (dual-side) mesh was placed around the defect. The minimum overlap beyond the original defect margin in both groups was 5 cm. Data regarding pre-operative parameters and postoperative outcomes, including pain and QoL at one week, one month, and three months, were recorded. A p-value of less than or equal to 0.05 was considered to be statistically significant. Results While the mean duration of surgery was longer, the cost of treatment was lower in group 1 (ventral-TAPP) with a p-value of <0.05 for both parameters. The length of hospital stay was significantly shorter in group 1 (ventral-TAPP), while the return to normal activity was similar in both groups. The visual analog scale (VAS) score for overall pain perception and the European registry for abdominal wall hernias (EuraHS; hernia-related QoL) score for 'Pain at Site' and 'Restriction of Activity' domains were significantly higher in group 2 (IPOM-plus) at one week. Conclusion Although the ventral-TAPP procedure requires more time and expertise to perform, the EuraHS QoL assessment at one week was better in group 1 (ventral-TAPP). Ventral-TAPP group scored better in terms of length of hospital stay and cost-effectiveness as well.

A rare presentation of linea alba hernia involving fibrolipoma of the hepatic round ligament: a case report and literature review

BACKGROUND

Linea alba hernias are relatively rare types of hernias. They manifest as small protrusions situated in the linea alba between the umbilicus and xiphoid cartilage. Usually, hernia contents comprise the pre-peritoneal fat, omentum, and gastrointestinal tract. However, very few cases of linea alba hernias involving the hepatic round ligament have been reported, to date.

CASE PRESENTATION

An 80-year-old woman presented with upper abdominal pain and a 1-week history of a mass in the upper midline. Abdominal computed tomography revealed adipose tissue protruding from the abdominal wall contiguous with the hepatic round ligament, suggesting a linea alba hernia. During surgery, the hernial sac content was found to be a mass, which was resected. A linea alba hernia defect measuring 20 mm was repaired using a mesh. Histopathological findings revealed that the mass included mature adipocyte proliferation with broad fibrous septa, which was diagnosed as fibrolipoma of the hepatic round ligament.

CONCLUSIONS

We report the first case of a linea alba hernia involving fibrolipoma of the hepatic round ligament worldwide and describe the clinical features, diagnosis, and surgical procedure with a literature review.

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).

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.

Open versus laparoscopic intraperitoneal on-lay mesh repair: A comparison of outcomes in small ventral hernia

PURPOSE

The ideal surgical treatment of small ventral hernias (defect less than 4 cm) is still debatable. In our study, we sought to compare the outcomes of open versus laparoscopic intraperitoneal on-lay mesh (IPOM) repair in small ventral hernias.

METHODS

Patients with a single ventral hernia defect of less than 4 cm undergoing surgical mesh repair between January 2016 and September 2018 were prospectively registered for this study. The minimum follow-up duration was 12 months. Patient demographics, operative findings and regular post-operative follow-up details including recurrence rates and complications were recorded and analysed.

RESULTS

41 patients underwent laparoscopic IPOM repair and 47 patients underwent open IPOM repair. The mean age for both groups is similar with no significant difference. The mean hernia defect size for the laparoscopic group is 2.8 cm (±0.8) whereas the mean hernia defect size for the open repair group is 2.1 cm (±0.4). The mean surgery duration for open IPOM repair was significantly shorter (59 min (±17) vs 74 min (±26); p = 0.001). There was no significant difference in the incidence of seroma formation and surgical site infections post-operatively. There was also no significant difference in both groups in terms of chronic pain and recurrence at 1-year follow-up.

CONCLUSION

Open IPOM repair for small ventral hernias may be superior to laparoscopic IPOM repair due to the shorter operative duration, single incision, and no additional risk of port-site hernias. There was no difference in chronic pain, wound infection and recurrence rate between the two groups.

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.

Long-term reoperation rate following primary ventral hernia repair: a register-based study

BACKGROUND

The aim of this study was to analyse the risk for reoperation following primary ventral hernia repair.

METHODS

The study was based on umbilical hernia and epigastric hernia repairs registered in the population-based Swedish National Patient Register (NPR) 2010-2019. Reoperation was defined as repeat repair after primary repair.

RESULTS

Altogether 29,360 umbilical hernia repairs and 6514 epigastric hernia repairs were identified. There were 624 reoperations registered following primary umbilical repair and 137 following primary epigastric repairs. In multivariable Cox proportional hazard analysis, the hazard ratio (HR) for reoperation was 0.292 (95% confidence interval (CI) 0.109-0.782) after open onlay mesh repair, 0.484 (CI 0.366-0.641) after open interstitial mesh repair, 0.382 (CI 0.238-0.613) after open sublay mesh repair, 0.453 (CI 0.169-1.212) after open intraperitoneal onlay mesh repair, 1.004 (CI 0.688-1.464) after laparoscopic repair, and 0.940 (CI 0.502-1.759) after other techniques, when compared to open suture repair as reference method. Following umbilical hernia repair, the risk for reoperation was also significantly higher for patients aged < 50 years (HR 1.669, CI 1.389-2.005), for women (HR 1.401, CI 1.186-1.655), and for patients with liver cirrhosis (HR 2.544, CI 1.049-6.170). For patients undergoing epigastric hernia repair, the only significant risk factor for reoperation was age < 50 years (HR 2.046, CI 1.337-3.130).

CONCLUSIONS

All types of open mesh repair were associated with lower reoperation rates than open suture repair and laparoscopic repair. Female sex, young age and liver cirrhosis were risk factors for reoperation due to hernia recurrence, regardless of method.

Safety and efficacy of absorbable and non-absorbable fixation systems for intraperitoneal mesh fixation: an experimental study in swine

PURPOSE

Choice of the best possible fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of the present study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation.

METHODS

Fourteen Landrace swine were utilized in the study. The experiment included two stages. Initially, four pieces of mesh (Ventralight ™ ST) sizing 10 × 5 cm were placed and fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. These defects were repaired primarily with absorbable suture before mesh implantation. Each mesh was anchored with a different tack device between Absorbatack™, Protack™, Capsure™, or Optifix™. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy via U-shaped incision to obtain the measurements for the outcome parameters. The primary endpoint of the study was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks.

RESULTS

Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Capsure™ tacks had higher peel strength when compared to Absorbatack™ (p = 0.028); Protack™ (p = 0.043); and Optifix™ (p = 0.009). No significant differences were noted regarding the extent of visceral adhesions (Friedman's test p value 0.854), the adhesion quality (Friedman's test p value 0.506), or the mesh shrinkage (Friedman's test p value = 0.827). Four out of the ten animals developed no adhesions at all 2 months after implantation.

CONCLUSION

Capsure™ fixation system provided higher peel strength that the other tested devices in our swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

Guidelines for Treatment of Umbilical and Epigastric Hernias From the European and Americas Hernia Societies-A Web-Based Survey on Surgeons' Opinion

Background and aims: The European and Americas Hernia Society's (EHS and AHS) Guidelines on the treatment of primary midline ventral hernias were launched to guide surgeons. As a part of a dissemination plan of the guideline, this study aimed to evaluate the level of consensus between recommendations and the current surgical practices of EHS and AHS members before implementation. Material and methods: A questionnaire was constructed including questions on the current practice of the members and nine selected key recommendations from the guidelines. An on-stage consensus voting was performed at the EHS Congress in Hamburg 2019 followed by a SurveyMonkey sent to all EHS and AHS members. Consensus with a recommendation was defined as an agreement of ≥70%. Results: A total of 178 votes were collected in Hamburg. A further 499/1,754 (28.4%) of EHS and 150/1,100 (13.6%) of AHS members participated in the SurveyMonkey. A consensus was reached for 7/9 (78%) of the recommendations. The two recommendations that did not reach consensus were on indication and the technique used for laparoscopic repair. In current practice, more AHS participants used a preformed patch; 50.7% (76/150) compared with EHS participants 32.1% (160/499), p < 0.001. Conclusion: A consensus was achieved for most recommendations given by the new guideline for the treatment of umbilical and epigastric hernias. Recommendations that did not reach consensus were on indication and technique for laparoscopic repair, which may reflect the lack of evidence on these topics.

Open Versus Laparoscopic Ventral Hernia Repair: A Randomized Clinical Trial

Introduction

With the advancement in technology as well as surgical techniques, laparoscopic ventral hernia repair (LVHR) is more commonly being performed as compared to open repair in various centres throughout the world. Our study aimed to compare the short-term operative outcomes between LVHR and open repair.

Materials and methods

Sixty patients diagnosed with noncomplicated ventral hernias were included in this prospective study and were randomly divided into the laparoscopic group and the open group. The two groups were compared to evaluate operative time, postoperative pain, length of hospital stay and time taken to return to normal activity. A p-value of less than 0.05 was considered to be statistically significant.

Results

Mean operative time was longer in LVHR (116 min) as compared to open repair (67 min)(p<0.01). Patients experienced more pain on the first and seventh postoperative days in the open group (p<0.01) and they also had a longer duration of hospital stay as compared to the laparoscopic group (6.23 ± 0.35 vs 2.17 ± 1.12 days, p = 0.02). Patients in the laparoscopic group returned to normal activity faster as compared to the open group (1.47 ± 0.11 vs 2.87 ± 0.34, p<0.01).

Conclusion

LVHR carries a significant advantage over open hernia repair, especially in terms of reduced postoperative pain, duration of hospital stay, and early resumption of normal activity.

Non-closure of the Free Peritoneal Flap During Laparoscopic Hernia Repair of Lower Abdominal Marginal Hernia: A Retrospective Analysis

Background: During lower abdominal marginal hernia repair, the peritoneal flap is routinely freed to facilitate mesh placement and closed to conclude the procedure. This procedure is generally called trans-abdominal partial extra-peritoneal (TAPE). However, the necessity of closing the free peritoneal flap is still controversial. This study aimed to investigate the safety and feasibility of leaving the free peritoneal flap in-situ. Methods: A retrospective review was conducted on 68 patients (16 male, 52 female) who underwent laparoscopic hernia repair between June 2014 and March 2021. Patients were diagnosed as the lower abdominal hernia and all required freeing the peritoneal flap during the operation. Patients were divided into 2 groups: one group was TAPE group with the closed free peritoneal flap, another group left the free peritoneal flap unclosed. Analyses were performed to compare both intraoperative parameters and postoperative complications. Results: There were no significant differences in demographic, comorbidity, hernia characteristics and ASA classification. The intra-operative bleeding volume, visceral injury, hospital stay, urinary retention, visual analog scale (VAS) score, dysuria, intestinal obstruction, surgical site infection, mesh infection, recurrence rate and hospital stay were similar among the two groups. Mean operative time of the flap closing procedure was higher than for patients with the free peritoneal flap left in-situ (p = 0.002). Comparisons of postoperative complications showed flap closure resulted in a higher incidence of seroma formation (p = 0.005). Conclusion: Providing a barrier-coated mesh is used during laparoscopic lower abdominal marginal hernia repair, it is safe to leave the free peritoneal flap in-situ and this approach may prevent the occurrence of seromas.

Intraperitoneal versus extraperitoneal mesh in minimally invasive ventral hernia repair: a systematic review and meta-analysis

PURPOSE

The ideal location for mesh placement in minimally invasive ventral hernia repair (VHR) is still up for debate. We undertook a systematic review and meta-analysis (SRMA) to evaluate the outcomes of patients who received intraperitoneal mesh versus those that received extraperitoneal mesh in minimally invasive VHR.

METHODS

We searched PubMed, EMBASE, Cochrane, and Scopus from inception to May 3, 2021. We selected studies comparing intraperitoneal mesh versus extraperitoneal mesh placement in minimally invasive VHR. A meta-analysis was done for the outcomes of surgical site infection (SSI), seroma, hematoma, readmission, and recurrence. A subgroup analysis was conducted for a subset of studies comparing patients who have undergone intraperitoneal onlay mesh (IPOM) versus extended totally extraperitoneal approach (e-TEP).

RESULTS

A total of 11 studies (2320 patients) were identified. We found no statistically significant difference between patients who received intraperitoneal versus extraperitoneal mesh for outcomes of SSI, seroma, hematoma, readmission, and recurrence [(RR 1.60, 95% CI 0.60-4.27), (RR 1.39, 95% CI 0.68-2.81), (RR 1.29, 95% CI 0.45-3.72), (RR 1.40, 95% CI 0.69-2.86), and (RR 1.22, 95% CI 0.22-6.63), respectively]. The subgroup analysis had findings similar to the overall analysis.

CONCLUSION

Based on short-term results, extraperitoneal mesh does not appear to be superior to intraperitoneal mesh in minimally invasive ventral hernia repair. The choice of mesh location should be based on the current evidence, surgeon, and center experience as well as individualized to each patient.

Are the relative benefits of open versus laparoscopic intraperitoneal mesh repair of umbilical hernias dependent on the diameter of the defect?

BACKGROUND

The aim of this study was to assess whether the respective values of open and laparoscopic intraperitoneal repairs of umbilical hernias are related to the European Hernia Society diameter of defects.

METHODS

This registry-based study compared the early and 2-year outcomes of 776 open versus 1,019 consecutive laparoscopic intraperitoneal repairs performed from 2011 to 2019.

RESULTS

Intraperitoneal mesh repair, either laparoscopic or open, was found to be a safe procedure at the 2-year follow-up. The incidence of reoperated bowel obstructions was 0.3%. Compared with the open group: (1) postoperative surgical site occurrences in small (<2 cm) or medium (2-4 cm) hernias (0.3% vs 2.4%; P = .041; 1.4% vs 5.9%; P = .0002); (2) recurrence rates in large (≥4 cm) umbilical hernias (0.0% vs 8.6%; P = .0195); and (3) cumulative reoperation rates (0.9% vs 2.2%; P = .021) were significantly better in the laparoscopic group. Conversely, the rate of early pain on day 1 and 1 month postsurgery was higher in the laparoscopic group, for all hernia sizes (P < .001). The rate of moderate or severe chronic pain at 2 years was significantly higher in the laparoscopic group (8.1% vs 2.4%; P = .049) for small hernias.

CONCLUSION

The respective benefit to drawback ratios for open versus laparoscopic intraperitoneal repairs were related to the European Hernia Society diameter of hernia defect. In medium-large hernias, the benefits of laparoscopic repair overrode its drawbacks. In small hernias, the low recurrence rate, reduced early and chronic pain, and better rate of ambulatory surgery suggest there is still a place for open repair.

Patient-reported outcomes after incisional hernia repair

Purpose

Patient-reported outcomes (PROs) are pivotal to evaluate the efficacy of surgical management. Debate persists on the optimal surgical technique to repair incisional hernias. Assessment of PROs can guide the selection of the best management of patients with incisional hernias. The objective of this cohort study was to present the PROs after incisional hernia repair at long term follow-up.

Methods

Patients with a history of incisional hernia repair were seen at the out-patient clinic to collect PROs. Patients were asked about the preoperative indication for repair and postoperative symptoms, such as pain, feelings of discomfort, and bulging of the abdominal wall. Additionally, degree of satisfaction was asked and Carolina Comfort Scales were completed.

Results

Two hundred and ten patients after incisional hernia repair were included with a median follow-up of 3.2 years. The main indication for incisional hernia repair was the presence of a bulge (60%). Other main reasons for repair were pain (19%) or discomfort (5%). One hundred and thirty-two patients (63%) reported that the overall status of their abdominal wall had improved after the operation. Postoperative symptoms were reported by 133 patients (63%), such as feelings of discomfort, pain and bulging. Twenty percent of patients reported that the overall status of their abdominal wall was the same, and 17% reported a worse status, compared to before the operation. Ten percent of the patients would not opt for operation in hindsight.

Conclusion

This study showed that a majority of the patients after incisional hernia repair still report pain or symptoms such as feelings of discomfort, pain, and bulging of the abdominal wall 3 years after surgery. Embedding patients’ expectations and PROs in the preoperative counseling discussion is needed to improve decision-making in incisional hernia surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02477-7.

A new criterion to predict recurrence after laparoscopic ventral hernia repair: mesh/defect area ratio

<b>Introduction:</b>Minimizing recurrence in hernia surgery is one of the major aims. Defining surgeon-dependent risk factors for recurrence is therefore of great importance in laparoscopic ventral hernia repair (LVHR). This study aims to analyze the predictive value of the mesh area/defect area ratio (M/D ratio) in terms of recurrence as a new criterion in LVHR.</br> </br> <b>Methods:</b> A total of 124 patients were enrolled in the study. Age, gender, hernia type, body mass index, defect size, size of the mesh, mesh overlapping, area of the defect, area of the mesh, M/D ratio, postoperative complications, follow-up time, recurrences and timing of recurrence were also recorded. The potential variables that may affect recurrence were examined by univariate and multivariate analysis.</br> </br> <b>Results:</b> There were 12 (9.7%) recurrences in our series. A statistically significant difference was found if either the mesh/defect ratio was ≤6 or >6 (p = 0.012). Multivariate analysis confirmed that M/D ratio was the only independent parameter for recurrence. </br></br><b>Conclusion:</b> Understanding M/D ratio concept and using it in surgical clinical practice may help reduce recurrence rates after LVHR.</br>

Laparoscopic Versus Open Incisional Hernia Repair: Long-Term Follow-up Results of a Randomized Clinical Trial

PURPOSE

Long-term extension of a previous randomized controlled clinical trial comparing open (OVHR) vs. laparoscopic (LVHR) ventral hernia repair, assessing recurrence, reoperation, mesh-related complications and self-reported quality of life with 10 years of follow-up.

METHODS

Eighty-five patients were followed up to assess recurrence (main endpoint), reoperation, mesh complications and death, from the date of index until recurrence, death or study completion, whichever was first. Recurrence, reoperation rates and death were estimated by intention to treat. Mesh-related complications were only assessed in the LVHR group, excluding conversions (intraperitoneal onlay; n = 40). Quality of life, using the European Hernia Society Quality of Life score, was assessed in surviving non-reoperated patients (n = 47).

RESULTS

The incidence rates with 10 person-years of follow-up were 21.01% (CI 13.24-33.36) for recurrence, 11.92% (CI: 6.60-21.53) for reoperation and 24.88% (CI 16.81-36.82) for death. Sixty-two percent of recurrences occurred within the first 2 years of follow-up. No significant differences between arms were found in any of the outcomes analyzed. Incidence rate of intraperitoneal mesh complications with 10 person-years of follow-up was 6.15% (CI 1.99-19.09). The mean EuraHS-QoL score with 13.8 years of mean follow-up for living non-reoperated patients was 6.63 (CI 4.50-8.78) over 90 possible points with no significant differences between arms.

CONCLUSION

In incisional ventral hernias with wall defects up to 15 cm wide, laparoscopic repair seems to be as safe and effective as open techniques, with no long-term differences in recurrence and reoperation rates or global quality of life, although lack of statistical power does not allow definitive conclusions on equivalence between alternatives.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov (NCT04192838).

Laparoscopic intraperitoneal versus enhanced-view totally extraperitoneal retromuscular mesh repair for ventral hernia: a retrospective cohort study

BACKGROUND

Laparoscopic enhanced-view totally extraperitoneal retromuscular repair (eTEP-RM) was recently introduced as a new technique for ventral hernia repair. The aim of the current study was to examine the outcomes of laparoscopic eTEP-RM compared with laparoscopic IPOM for patients with primary ventral and incisional hernia.

METHODS

This was a retrospective cohort study of patients undergoing laparoscopic ventral hernia repair at a single University Hospital from June 2017 to November 2020. Medical charts of all patients subjected to IPOM and eTEP-RM were evaluated to identify patient- and procedure related variables, as well as postoperative 30-day outcomes.

RESULTS

A total of 72 patients were included in the study, 43 and 29 of whom underwent IPOM and eTEP-RM repair, respectively. Patient demographics showed no differences in terms of gender, age, smoking and comorbidity. The median age was 57 years and body mass index 30.5 kg/m². The rate of patients with incisional hernia was higher in the IPOM group (39.5% vs. 20.7%, p = 0.154). There was no difference in horizontal and vertical hernia size defect. The duration of surgery was significantly shorter for IPOM (mean 82.4 vs. 103.4 min, p = 0.010), whereas the length of stay was significantly longer after IPOM (median 1 days vs. 0 days (p < 0.001). The rate of patients requiring postoperative transversus abdominis plane (TAP) block or epidural analgesia was significantly higher after IPOM (33% vs. 0%, p = 0.002). A subgroup analysis on patients undergoing primary ventral hernia showed similar results.

CONCLUSION

The study found laparoscopic eTEP-RM safe and effective compared to traditional laparoscopic IPOM. The patients undergoing eTEP-RM had significantly reduced need for additional analgesic treatment and length of stay.

Preaponeurotic endoscopic repair (REPA) of diastasis recti: a single surgeon's experience

BACKGROUND

Diastasis recti is a pathology that affects not only the abdominal wall but also the stability of lumbopelvic muscles, consequently altering urinary and digestive functionality. Preaponeurotic endoscopic repair (REPA) is an endoscopic alternative to tummy tuck for the treatment of diastasis. In this study, the outcomes of REPA application by a single surgeon are presented.

METHODS

A total of 172 patients underwent REPA for the treatment of diastasis recti between August 2017 and December 2019. One hundred twenty-four patients were followed for at least one year. Sixty-three patients responded to a survey on satisfaction and quality of life 12 months after surgery.

RESULTS

Three (2.4%) recurrences occurred, of which two occurred in the same patient. The main postoperative complications observed were 12 (9.7%) seromas, 3 (2.4%) haematomas, a single wound infection, 3 (2.4%) cases of skin fold formation, and a case of trophic skin lesion that required negative pressure therapy. Quality of life after surgery, as reported by 63 patients who responded to the survey, was satisfactory.

CONCLUSIONS

REPA is a safe and effective technique for diastasis recti treatment, representing a valid alternative to abdominoplasty. Since there is no need to access the peritoneal cavity and the mesh is onlay, there are no risks of bowel damage or adhesions between the intestine and prosthesis.

OPEN VS LAPAROSCOPIC HERNIA REPAIR IN THE BRAZILIAN PUBLIC HEALTH SYSTEM. AN 11-YEAR NATIONWIDE POPULATION-BASED STUDY

BACKGROUND

Abdominal wall hernia is one of the most common surgical pathologies. The advent of minimally invasive surgery raised questions about the best technique to be applied, considering the possibility of reducing postoperative pain, a lower rate of complications, and early return to usual activities.

OBJECTIVE

To evaluate the frequency of open and laparoscopic hernioplasties in Brazil from 2008 to 2018, analyzing the rates of urgent and elective surgeries, mortality, costs, and the impact of laparoscopic surgical training on the public health system.

METHODS

Nationwide data from 2008 to 2018 were obtained from the public health registry database (DATASUS) for a descriptive analysis of the selected data and parameters.

RESULTS

2,671,347 hernioplasties were performed in the period, an average of 242,850 surgeries per year (99.4% open, 0.6% laparoscopic). The economically active population (aged 20-59) constituted the dominant group (54.5%). There was a significant reduction (P<0.01) in open surgeries, without a compensatory increase in laparoscopic procedures. 22.3% of surgeries were urgent, with a significant increase in mortality when compared to elective surgeries (P<0.01). The distribution of laparoscopic surgery varied widely, directly associated with the number of digestive surgeons.

CONCLUSION

This study presents nationwide data on hernia repair surgeries in Brazil for the first time. Minimally invasive techniques represent a minor portion of hernioplasties. Urgent surgeries represent a high percentage when compared to other countries, with increased mortality. The data reinforce the need for improvement in the offer of services, specialized training, and equalization in the distribution of procedures in all regions.

Open versus laparoscopic umbilical and epigastric hernia repair: nationwide data on short- and long-term outcomes

BACKGROUND

It is unclear whether an open or laparoscopic approach results in the best outcomes for repair of umbilical and epigastric hernias. The aim of the study was to evaluate the rates of 90-day readmission and reoperation for complication, together with rate of operation for recurrence after either open or laparoscopic mesh repair for primary umbilical or epigastric hernias with defect widths above 1 cm.

METHODS

A merge of data between the Danish Hernia Database and the National Patient Registry provided data from 2007 to 2018 on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence.

RESULTS

A total of 6855 patients were included, of whom 4106 (59.9%) and 2749 (40.1%) patients had an open or laparoscopic repair, respectively. There were significantly more patients readmitted with a superficial surgical site infection 2.5% (102/4106) after open repair compared with laparoscopic repair (0.5% (15/2749), P < 0.001. The 90-day reoperation rate for complications was significantly higher for open repairs 5.0% (205/4106) compared with laparoscopic repairs 2.7% (75/2749), P < 0.001. The incidence of a reoperation for a severe condition was significantly increased after laparoscopic repair 1.5% (41/2749) compared with open repair 0.8% (34/4106), P = 0.010. The 4-year cumulative incidence of operation for hernia recurrence was 3.5% after open and 4.2% after laparoscopic repairs, P = 0.302.

CONCLUSIONS

Recurrence rates were comparable between open and laparoscopic repair of umbilical and epigastric hernias. Open repair was associated with a significantly higher rate of readmission and reoperation due to surgical site infection, whereas the rate of reoperation due to a severe complication was significantly higher after laparoscopic repair.

Open versus laparoscopic incisional hernia repair: nationwide database study

Background

Although laparoscopic repair of incisional hernias decreases the incidence of wound complications compared with open repair, there has been rising concern related to intraperitoneal mesh placement. The aim of this study was to examine outcomes after open or laparoscopic elective incisional hernia mesh repair on a nationwide basis.

Methods

This study analysed merged data from the Danish Hernia Database and the National Patient Registry on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence among patients who underwent primary repair of an incisional hernia between 2007 and 2018.

Results

A total of 3090 (57.5 per cent) and 2288 (42.5 per cent) patients had surgery by a laparoscopic and open approach respectively. The defect was closed in 865 of 3090 laparoscopic procedures (28.0 per cent). The median follow-up time was 4.0 (i.q.r. 1.8–6.8) years. Rates of readmission (502 of 3090 (16.2 per cent) versus 442 of 2288 (19.3 per cent); P = 0.003) and reoperation for complication (216 of 3090 (7.0 per cent) versus 288 of 2288 (12.5 per cent); P < 0.001) were significantly lower for laparoscopic than open repairs. Reoperation for bowel obstruction or bowel resection was twice as common after laparoscopic repair compared with open repair (20 of 3090 (0.6 per cent) versus 6 of 2288 (0.3 per cent); P = 0.044). Patients were significantly less likely to undergo repair of recurrence following laparoscopic compared with open repair of defect widths 2–6 cm (P = 0.002).

Conclusion

Laparoscopic intraperitoneal mesh repair for incisional hernia should still be considered for fascial defects between 2 and 6 cm, because of decreased rates of early complications and repair of hernia recurrence compared with open repair.

Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature

With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.

Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh: The PROVE-IT Randomized Clinical Trial

Importance

Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.

Objective

To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain.

Design, Setting, and Participants

A registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.

Interventions

Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh.

Main Outcomes and Measures

The trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost.

Results

Seventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).

Conclusions and Relevance

Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.

Trial Registration

ClinicalTrials.gov Identifier: NCT03283982.

A peritoneal defect covered by intraperitoneal mesh prosthesis effects an increased and distinctive foreign body reaction in a minipig model

BACKGROUND

The incidence of incisional hernia is with up to 30% one of the frequent long-term complication after laparotomy. After establishing minimal invasive operations, the laparoscopic intraperitoneal onlay mesh technique (lap. IPOM) was first described in 1993. Little is known about the foreign body reaction of IPOM-meshes, which covered a defect of the parietal peritoneum. This is becoming more important, since IPOM procedure with peritoneal-sac resection and hernia port closing (IPOM plus) is more frequently used.

METHODS

In 18 female minipigs, two out of three Polyvinylidene-fluoride (PVDF) -meshes (I: standard IPOM; II: IPOM with modified structure [bigger pores]; III: IPOM with the same structure as IPOM II + degradable hydrogel-coating) were placed in a laparoscopic IPOM procedure. Before mesh placement, a 2x2cm peritoneal defect was created. After 30 days, animals were euthanized, adhesions were evaluated by re-laparoscopy and mesh samples were explanted for histological and immunohistochemichal investigations.

RESULTS

All animals recovered after implantation and had no complications during the follow-up period. Analysing foreign body reaction, the IPOM II mesh had a significant smaller inner granuloma, compared to the other meshes (IPOM II: 8.4 µm ± 1.3 vs. IPOM I 9.1 µm ± 1.3, p < 0.001). The degradable hydrogel coating does not prevent adhesions measured by Diamond score (p = 0.46). A peritoneal defect covered by a standard or modified IPOM mesh was a significant factor for increasing foreign body granuloma, the amount of CD3+ lymphocytes, CD68+ macrophages and decrease of pore size.

CONCLUSION

A peritoneal defect covered by IPOM prostheses leads to an increased foreign body reaction compared to intact peritoneum. Whenever feasible, a peritoneal defect should be closed accurately before placing an IPOM-mesh to avoid an excessive foreign body reaction and therefore inferior biomaterial properties of the prosthesis.

Needlescopic surgery for large umbilical hernia in a patient with morbid obesity using intraperitoneal onlay mesh with fascial defect closure: a case report

Background

The European and American guidelines recommend that symptomatic umbilical hernias (UHs) are repaired using an open approach with a preperitoneal flat mesh. However, the standard treatment procedure for large UH in patients with extreme obesity is yet to be established. Here, we present the first case of a patient with morbid obesity undergoing laparoscopic UH repair using needlescopic instruments and an intraperitoneal onlay mesh plus repair (IPOM plus).

Case presentation

A 29-year-old man, who was classified as morbidly obese (body mass index, 36.7 kg/m²) noticed a reducible nontender mass in the umbilical region and was subsequently diagnosed with an UH, with a diameter of 4 cm. Laparoscopic IPOM plus repair was planned using a needlescopic method for a large UH in the patient with morbid obesity. A 3-mm rigid laparoscope was mainly used in the procedure. After a 12-mm trocar and two 3-mm trocars were inserted, fascial defect closure was performed using intracorporeal suturing with 0 monofilament polypropylene threads. Then, IPOM was performed laparoscopically using an 11.4-cm round mesh coated with collagen to prevent adhesions. The operative time and blood loss were 57 min and 1 g, respectively. The postoperative course was uneventful.

Conclusions

Reduced-port laparoscopic surgery using needlescopic instruments and an IPOM plus technique is a minimally invasive and convenient combination option for large UH in a patient with morbid obesity.

[Minimally invasive ventral hernia repair: apply or save?]

Treatment of patients with ventral hernias remains one of the most pressing problems of abdominal surgery. Surgeons are trying to find a «gold standard» for the treatment of this pathology. Great hopes are placed on minimally invasive techniques, however, due to their high cost, they do not yet find mass distribution in everyday practice. In our opinion, this is short-sighted. We tried to analyze the feasibility of using minimally invasive techniques in the treatment of patients with ventral hernias of various locations, from the position of clinical and economic efficiency.

Long-Term Outcomes of Ventral Hernia Repair: An 11-Year Follow-Up

Background: Ventral hernia repair (VHR) is one of the most common general surgery procedures; however, few studies with long-term follow-up of VHR outcomes exist.

Methods: We performed a retrospective review of VHRs performed from 2000 to 2009 at a single institution. Our primary outcome was recurrence, and secondary outcomes were reoperations and complications including seroma, hematomas, abdominal wall abscess, wound infections, and mesh infections.

Results: Our sample population (n=420; mean age 46.3±11.7 years) included 230 females (54.8%), and cases included laparoscopic (n=31; 7.5%), laparoscopic converted to open (n=7; 1.7%), and open (n=373, 90%). As compared to suture repairs, mesh repair was associated with lower rates of complications (25.7% vs 29.5%, p=0.10) and recurrence (12.8% vs 15.2%, p=0.67). Laparoscopic repairs had lower rates of complications than open repairs (25% vs 26.8%; p=0.70) but similar rates of recurrence (13.8% and 13.6%; p=0.53). After logistic regression, obesity, chronic obstructive pulmonary disease, component separation technique, and prolonged operating time (>75th percentile) were associated with increased complications.

Conclusion: Obesity is a modifiable risk factor and must be addressed in patients undergoing VHRs. Mesh repair does not increase the risk of adverse long-term outcomes and may be performed safely in patients undergoing VHR.

Laparoscopic versus open ventral hernia repair in the elderly: a propensity score-matched analysis

BACKGROUND

Ventral hernia repair is common in the expanding aging population, but remains challenging due to their frequent comorbidities. The purpose of this study is to compare the surgical outcomes of open vs. laparoscopic ventral hernia repair in elderly patients.

METHODS

Patients ≥ 65 years of age that underwent elective open or laparoscopic ventral hernia repair were identified from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. To reduce potential selection bias, propensity scores were created for the likelihood of undergoing laparoscopic surgery based on patients' demographics and comorbidities. Patients were matched based on the logit of the propensity scores. Thirty-day surgical outcomes were compared after matching using Chi-square test for categorical variables and the Wilcoxon Rank-Sum test for continuous variables.

RESULTS

35,079 (71.1%) and 14,270 (28.9%) patients underwent open and laparoscopic ventral hernia repairs, respectively. Laparoscopic surgery was associated with a lower overall morbidity (5.9% vs. 9.1%; p < 0.001) compared to open repair. The incidence of surgical site infections (1.1% vs. 3.5%; p < 0.001), post-operative infections (2.7% vs. 3.6%; p < 0.001), and reoperation (1.7% vs. 2.1%; p = 0.009) were all lower after laparoscopic repair. All other major surgical outcomes were either better with laparoscopy or comparable between both treatment groups except for operative time.

CONCLUSION

Although open surgery remains the most prevalent in the elderly population, the results of this study suggest that laparoscopic surgery is safe and associated with a lower risk of overall morbidity, surgical site infections, and reoperation.