Nomenclature in Abdominal Wall Hernias: Is It Time for Consensus?

Abdominal Wall Reconstruction in Abdominal Wall Endometriosis: A Case Report and Literature Review

Abdominal wall endometriosis (AWE) is a rare condition representing 1% of patients operated for endometriosis. We describe a case of a 26-year-old woman, with a history of cesarean delivery, who presented with cyclical pain and a subcutaneous mass in the lower abdomen. Where most AWE lesions may be surgically managed by a single surgeon, imaging revealed an unusually large lesion (13 × 4 × 10 cm) involving the rectus abdominis muscle. Plastic, gynecologic, and general surgeons combined their expertise to conduct AWE excision combined with miniabdominoplasty in a single procedure. After resection, a retrorectus mesh (Rives-Stoppa technique) reinforced the primarily closed posterior rectus sheath and an inlay mesh bridged the defect left in the anterior rectus sheath. The patient was discharged 3 days postoperatively, had minimal pain complaints, and was satisfied with cosmetic results at 1-month and later follow ups. One year postoperatively, she gave uncomplicated vaginal birth. We conclude that, in select cases, management of a large, symptomatic AWE may benefit from a multidisciplinary approach, where symptom relief and an aesthetically pleasing result for the patient can be achieved in a single procedure. We distinctively describe double mesh repair as a viable consideration for reconstruction in AWE and review current considerations in mesh repair of the abdominal wall. Further studies into this topic are warranted.

Suture versus open mesh repair for small umbilical hernia: Results of a propensity-matched cohort study

BACKGROUND

The objective was to compare the outcomes of open mesh repair versus suture repair for small (≤1 cm in diameter) umbilical hernia. The primary endpoint was the 30-day outcomes including pain, and secondary endpoints were the 2-year outcomes including recurrences and patient-reported outcomes.

METHODS

This propensity-matched, multicenter study was carried out on data collected prospectively in the Hernia-Club database between 2011 and 2021. A total of 590 mesh repairs and 590 suture repairs were propensity score matched (age, sex, body mass index) at a ratio of 1:1. Postoperative pain was assessed using the Verbal Rating Scale-4 and 0‒10 Numerical Rating Scale-11.

RESULTS

Mesh insertion was intraperitoneal in 331 patients (56.1%), extraperitoneal in 249 (42.2%), and onlay in 10 (1.7%). The rate of 30-day complications and Numerical Rating Scale-11 pain scores on postoperative days 8 and 30 were similar between the groups, including surgical site occurrences (2.2 vs 1.4% after suture repair). At 1 month, postoperative discomfort (sensation of something different from before) was significantly (P < .0001) more frequent after mesh repair, whereas the rate of relevant (moderate or severe) pain (mesh repair: 1.1% vs suture repair: 2.6%) and the distribution of Numerical Rating Scale-11 scores did not differ between the groups. At the 2-year follow-up, mesh repair patients had fewer reoperated recurrences (0.2% vs 1.7%; P = .035) and no more pain or discomfort than suture repair patients.

CONCLUSION

Both techniques are effective and safe. Mesh repair is likely to reduce the rate of recurrences. Concerns about postoperative pain and infection might not prevent the use of mesh in smallest umbilical hernias.

Open vs. minimally invasive sublay incisional hernia repair. Is there a risk of overtreatment? EVEREG registry analysis

INTRODUCTION

Incisional hernia (IH) is a very common surgical procedure. Registries provide real world data. The objective is to analyze the open and minimally invasive (MIS) sublay technique (with or without associated components separation [CS]) in IH cases from the EVEREG registry and to evaluate the evolution over time of the techniques.

METHODS

All patients in EVEREG from July 2012 to December 2021 were included. The characteristics of the patients, IH, surgical technique, complications and mortality in the first 30 days were collected. We analyzed Group 1 (open sublay vs MIS sublay, without CS), Group 2 (open sublay vs MIS sublay, with CS) and Group 3 where the evolution of open and MIS techniques was evaluated over time.

RESULTS

4867 IH were repaired using a sublay technique. Group 1: 3739 (77%) open surgery, mostly midline hernias combined (P = .016) and 55 (1%) MIS, mostly lateral hernias (LH) (P = .000). Group 2: 1049 (21.5%) open surgery and 24 (0.5%) MIS. A meaningful difference (P = .006) was observed in terms of transverse diameters (5.9 (SD 2.1) cm for the MIS technique and 10.11 (SD 4.8) for the open technique). The LH MIS associated more CS (P = .002). There was an increase in the use of the sublay technique over time (with or without CS).

CONCLUSION

Increased use of the sublay technique (open and MIS) over time. For some type of hernia (LH) the MIS sublay technique with associated CS may have represented an overtreatment.

Laparoscopic subcutaneous onlay mesh repair for ventral hernia: Our early experience

Introduction

Repair of the ventral hernia is an ongoing challenge in surgery, and a number of surgical techniques have been developed ranging from direct suturing techniques to the use of various mesh types in different planes of the abdominal wall to close the defect and strengthen the musculofascial tissue. Laparoscopic subcutaneous onlay mesh (SCOM) repair is a novel procedure developed recently for ventral hernia repair. We would like to share our experience with laparoscopic SCOM repair.

Patients and Methods

This is a prospective observational study of patients who have undergone ventral hernia repair at Bangalore Endoscopic Surgery Training Institute and Research Centre from June 2020 to June 2022. A total of 20 patients are included in this study.

Statistical Analysis Used

The data were entered into MS Excel and analysed.

Results

A total of 20 patients underwent SCOM repair with a defect size measuring up to 8 cm × 8 cm and a mean operative time of 117 min. Three patients had seroma formation and one patient had surgical site infection. No recurrence is seen after 1-year 2-month follow-up.

Conclusion

SCOM repair is the newer approach to ventral hernia repair with the advantage over open onlay mesh repair in terms of less pain and better cosmesis. SCOM repair avoids intraperitoneal dissection which may lead to visceral injuries as well as subsequent intraperitoneal adhesions. The acceptance of such surgeries would depend on further long-term studies.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study

INTRODUCTION

Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair.

METHODS

A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1 month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program.

RESULTS

One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9 days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5 days for group 3 (p < 0.005).

CONCLUSION

Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

Is There Indication for the Use of Biological Mesh in Cancer Patients?

Up to 28% of all patients who undergo open surgery will develop a ventral hernia (VH) in the post-operative period. VH surgery is a debated topic in the literature, especially in oncological patients due to complex management. We searched in the surgical database of the Hepatobiliary Unit of the National Cancer Institute of Naples “G. Pascale Foundation” for all patients who underwent abdominal surgery for malignancy from January 2010 to December 2018. Our surgical approach and our choice of mesh for VH repair was planned case-by-case. We selected 57 patients that fulfilled our inclusion criteria, and we divided them into two groups: biological versus synthetic prosthesis. Anterior component separation was used in 31 patients (54.4%) vs. bridging procedure in 26 (45.6%). In 41 cases (71.9%), we used a biological mesh while a synthetic one was adopted in the remaining patients. Of our patients, 57% were male (33 male vs. 24 female) with a median age of 65 and a mean BMI of 30.8. We collected ventral hernia defects from 35 cm² to 600 cm² (mean 205.2 cm²); 30-day complications were present in 24 patients (42.1%), no 30-day mortality was reported, and 21 patients had a recurrence of pathology during study follow-up. This study confirms VH recurrence risk is not related with the type of mesh but is strongly related with BMI and type of surgery also in oncological patients.

Posterior component separation with transversus abdominis muscle release versus mesh-only repair in the treatment of complex ventral-wall hernia: a randomized controlled trial

Background

Complex ventral hernias (VHs) represent a real challenge to both general and plastic surgeons. This study aims to compare Sublay Mesh-Only Repair to Posterior Component Separation “PCS” with Transversus Abdominis Release “TAR” in the treatment of complex ventral-wall hernias (VHs).

Methods

This a randomized, controlled, intervention, including two parallel groups: A; Sublay Mesh-Only Repair and Group B; “TAR”. Consecutive patients of both genders aged between 18 and 65 years old with complex VHs presented at Mansoura University Hospitals including large-sized abdominal-wall hernia ≥ 10 cm in width, loss of domain ≥ 20%, multiple hernial defects, or recurrent hernias. Immuno-compromised patients, patients with liver impairment, or severe heart failure were considered an exclusion criterion. The primary outcome is the recurrence rate after 12-months following the procedure.

Results

Fifty-six patients were recruited in this study. There was no significant difference between both groups regarding recurrence. However, there was significant differences between both groups regarding seroma favoring mesh-only repair.

Conclusions

Although TAR may be associated with longer operative times and more blood losses, these were not found to be statistically significant. Postoperative complication, except for seroma, and recurrence rates were comparable in both groups.

Trail registration The study was registered on clicaltrials.gov “NCT04516031”.

The Hernia Coding Conundrum: A Potential Benefit of the International Hernia Collaboration Online Social Media Platform

BACKGROUND

Despite various resources on the subject, there remain questions regarding billing and coding hernia surgery. Recently, social media has been used to disseminate information in about surgery. The purpose of this project is to evaluate posts relating to coding through one online social media platform.

MATERIALS AND METHODS

The International Hernia Collaboration Facebook site was queried with terms relating to coding. Inclusion criteria were post discussing coding on the site. Posts relating to coding were reviewed by at least 2 reviewers. Number of comments, main topic of question, and additional information about codes were recorded and descriptive statistics generated.

RESULTS

There were 100 posts found using the search term coding of which 85 met inclusion criteria. Post ranged from 5/2014 to 6/2021. Posts were from 72 surgeons with an average of 12 responses per post. Posts most commonly related to ventral and incisional hernia (53) followed by inguinal (18), other (19), diaphragm (4), and inguinal/ventral (1). For the ventral/incisional hernia, the most common posts were related to myofascial release techniques (29) followed by mesh (6), botox (5), hernia prevention (3), other (3), robotic surgery (2), open surgery (2), rectus diastasis (2), and laparoscopy (2).

DISCUSSION

There remains controversies over coding for hernia repair particularly myofascial releases in ventral and incisional and new techniques using the robot. An online social media platform appears to be a viable way to disseminate coding information and generate discussion. Further study is needed to evaluate the role of social media for coding.

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.

Systematic review and meta-analysis of risk factors for Mesh infection following Abdominal Wall Hernia Repair Surgery

BACKGROUND

Surgical Mesh Infection (SMI) after Abdominal Wall Hernia Repair (AWHR) represents a catastrophic complication. We performed a systematic review and meta-analysis to analyze the risk factors for SMI in the context of AWHR.

METHODS

PubMed, Embase, Scielo, and LILACS were searched without language or time restrictions from inception until June 2021. Articles evaluating the association between demographic, clinical, laboratory and surgical characteristics with SMI in AWHR were included.

RESULTS

23 studies were evaluated, comprising a total of 118,790 patients (98% males; mean age 56.5 years) with a mesh infection pooled prevalence of 4%. Significant risk factors for SMI were type 2 diabetes mellitus, obesity, smoking history, steroids use, ASA III/IV, laparotomy vs laparoscopy, emergency surgery, duration of surgery and onlay mesh position vs sublay. The quality of evidence was regarded as very low-moderate.

CONCLUSION

Several factors, highlighting sociodemographic characteristics, comorbidities, and the clinical scenario, may increase the risk of developing mesh infections in AWHR. The recognition and mitigation of these may significantly reduce mesh infection rates in this context.

The Plane of Mesh Placement Does Not Impact Abdominal Donor Site Complications in Microsurgical Breast Reconstruction

BACKGROUND

Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated.

METHODS

We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88).

RESULTS

Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications.

CONCLUSIONS

Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.

Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review

BACKGROUND

A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different countries. The aim of this systematic review is to assess the safety and feasibility of different named techniques with the same surgical concept.

METHODS

The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score system was used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study designs, risk of bias, publication bias, heterogeneity, and statistical analysis.

RESULTS

The systematic literature search found 2548 articles, 317 of which were duplicates and excluded from analysis. The titles and abstracts from the remaining 2231 articles were assessed. After careful evaluation, 2125 articles were determined to be unrelated to our study and subsequently excluded. The full text of the remaining 106 articles was thoroughly assessed. Case reports, editorials, letters to the editor, and general reviews were then excluded. A total of 13 articles were ultimately included for this review, describing a similar subcutaneous endoscopic approach for repair of concomitant ventral hernias and rectus diastasis defined under nine different named techniques on 716 patients. The number of patients in those studies varied from 10 to 201. The mean operative time varied from 68.5 to 195 min. The most common complication was seroma, followed by pain requiring intervention, hematoma, and surgical site infection.

CONCLUSIONS

There are a few technique variations described in different studies, but with no significant differences in outcomes. We, therefore, propose to unify these procedures under one term, ENDoscopic Onlay Repair (ENDOR). This technique has shown to be effective and safe, with seroma being the most common complication.

Caesarean Scar Endometriosis May Require Abdominoplasty

Endometriosis is defined as an ectopic presence of endometrium-like tissue outside uterine cavity, which most commonly involves intraperitoneal organs. However, one of the less frequent forms of the disease is abdominal wall endometriosis usually developing in surgical scars following obstetric and gynaecological surgeries involving uterine cavity entering, that is, caesarean section, myomectomy or hysterectomy. In this case report we present a case of a patient with extensive caesarean scar endometriosis, who required complex surgical management. Successful surgical treatment involved not only radical tumour resection and application of mesh in postoperative hernia prevention but also adequate wound closure ensuring satisfactory cosmetic results, which was most challenging. The abdominal wall defect could not be sutured by traditional technique, thus polypropylene mesh was used and partial abdominoplasty was performed. The wound healed without complication and 24-month follow-up showed no evidence of local recurrence and satisfactory cosmetic result. In case of extensive endometrial abdominal wall tumours surgical treatment may involve application of advanced plastic surgery techniques, like abdominoplasty or skin/musculocutaneous flaps transposition.

Wide variation in surgical techniques to repair incisional hernias: a survey of practice patterns among general surgeons

BACKGROUND

The purpose of this research was to examine the self-reported practice patterns of Canadian general surgeons regarding the elective repair of incisional hernias.

METHODS

A mail survey was sent to all general surgeons in Canada. Data were collected regarding surgeon training, years in practice, practice setting and management of incisional hernias. Surgeons were asked to describe their usual surgical approach for a patient with a midline incisional hernia and a 10 × 6 cm fascial defect.

RESULTS

Of the 1876 surveys mailed out 555 (30%) were returned and 483 surgeons indicated that they perform incisional hernia repair. The majority (62%) have been in practice > 10 years and 73% regularly repair incisional hernias. In response to the clinical scenario of a patient with an incisional hernia, 74% indicated that they would perform an open repair and 18% would perform a laparoscopic repair. Ninety eight percent of surgeons would use mesh, 73% would perform primary fascial closure and 47% would perform a component separation. The most common locations for mesh placement were intraperitoneal (46%) and retrorectus/preperitoneal (48%). The most common repair, which was reported by 37% of surgeons, was an open operation, with mesh, with primary fascial closure and a component separation.

CONCLUSIONS

While almost all surgeons who perform incisional hernia repairs would use permanent mesh, there was substantial variation reported in surgical approach, mesh location, fascial closure and use of component separation techniques. It is unclear how this variability may impact healthcare resources and patient outcomes.

Measuring quality of life in patients with abdominal wall hernias: a systematic review of available tools

INTRODUCTION

Abdominal wall herniation (AWH) is an increasing problem for patients, surgeons, and healthcare providers. Surgical-site specific outcomes, such as infection, recurrence, and mesh explantation, are improving; however, successful repair still exposes the patient to what is often a complex major operation aimed at improving quality of life. Quality-of-life (QOL) outcomes, such as aesthetics, pain, and physical and emotional functioning, are less often and less well reported. We reviewed QOL tools currently available to evaluate their suitability.

METHODS

A systematic review of the literature in compliance with PRISMA guidelines was performed between 1st January 1990 and 1st May 2019. English language studies using validated quality-of-life assessment tool, whereby outcomes using this tool could be assessed were included.

RESULTS

Heterogeneity in the QOL tool used for reporting outcome was evident throughout the articles reviewed. AWH disease-specific tools, hernia-specific tools, and generic tools were used throughout the literature with no obviously preferred or dominant method identified.

CONCLUSION

Despite increasing acknowledgement of the need to evaluate QOL in patients with AWH, no tool has become dominant in this field. Assessment, therefore, of the impact of certain interventions or techniques on quality of life remains difficult and will continue to do so until an adequate standardised outcome measurement tool is available.

Robotic-assisted pulley technique for the ventral hernia

When approaching complex abdominal wall hernias at either index operation or a subsequent reoperation for recurrent incarcerated abdominal wall hernias, a majority of surgeons consider mesh placement a key step in the prevention of a future recurrence. While the laparoscopic and open approaches show no significant difference in hernia recurrence, the laparoscopic approach to complex abdominal wall hernias does reduce surgical-site infection, postoperative ileus, improves short-term quality-of-life scores, and reduces hospital length of stay (Davies et al. in Am Surg 78(8):888-892, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500604/ , 2012, McGreevy et al. in Surg Endosc 17(11):1778-1780, https://www.ncbi.nlm.nih.gov/pubmed/12958679 , 2003, Bittner et al. in Surg Endosc 33:3069-3139, https://doi.org/10.1007/s00464-019-06907-7 , 2019). In this paper, we describe a robotic approach with a pulley technique to the fixation of polypropylene mesh in complex abdominal wall reconstruction. Our primary aim is to offer a new perspective to the re-creation of challenging abdominal walls and to encourage other surgeons to gain proficiency in the robotic approach. Additionally, the material cost to the technique is lower than that of self-expanding or deployable mesh reinforcements used in other laparoscopic approaches. Over time, as an institution breaks even on the cost of a robot with their return on investment, this technique offers potential cost-saving.

A comparison of robotic mesh repair techniques for primary uncomplicated midline ventral hernias and analysis of risk factors associated with postoperative complications

PURPOSE

We aim to compare short-term outcomes of robotic intraperitoneal onlay (rIPOM), transabdominal preperitoneal (rTAPP) and retromuscular (rRM) repair for uncomplicated midline primary ventral hernias (PVH) and determine risk factors associated with postoperative complications.

METHODS

The three groups were compared in terms of pre-, intra-, and post-operative variables. Postoperative complications were assessed using previously validated classifications. Univariate analyses were conducted to determine which variables influence postoperative complications (up to 90 days), followed by a multivariate regression analysis revealing statistically important risk factors.

RESULTS

A total of 269 patients who underwent robotic PVH repair patients were grouped as rIPOM (n = 90), rTAPP (n = 108), and rRM (n = 71). rRM repair allowed for the use of larger-sized meshes for larger defects; however, it was associated with higher-grade complications. rTAPP repair resulted in the lowest morbidity and offered the highest mesh-to-defect ratio for smaller-sized hernias. Operative time for the rRM group was longer. The rIPOM group had a higher morbidity, likely due to higher frequency of minor complications, as compared to rTAPP and rRM groups. Multivariate regression analysis revealed that coronary artery disease, absence of defect closure, intraperitoneally placed mesh, and skin-to-skin time (minutes) were significantly associated with postoperative complications.

CONCLUSION

Robotic PVHR contributes multiple techniques to a surgeon's armamentarium, such as IPOM, TAPP, and RM mesh placements. Patient characteristics as well as the potential consequences of each technique need to be taken into consideration when deciding the appropriate approach for the repair of primary uncomplicated midline ventral hernias.

International classification of abdominal wall planes (ICAP) to describe mesh insertion for ventral hernia repair

BACKGROUND

Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes.

METHODS

A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed.

RESULTS

Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes.

CONCLUSION

Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

Open Intraperitoneal Onlay Mesh (IPOM) Technique for Incisional Hernia Repair

In an Expert Consensus Guided by Systematic Review the panel agreed that for open elective incisional hernia repair sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. Accordingly, the available literature on the open IPOM technique was searched and evaluated. Material and Methods: A systematic search of the available literature was performed in July 2018 using Medline, PubMed, and the Cochrane Library. Forty-five publications were identified as relevant for the key question. Results: Compared to laparoscopic IPOM, the open IPOM technique was associated with significantly higher postoperative complication rates and recurrence rates. For the open IPOM with a bridging situation the postoperative complication rate ranges between 3.3 and 72.0% with a mean value of 20.4% demonstrating high variance, as did the recurrence rate of between 0 and 61.0% with a mean value of 12.6%. Only on evaluation of the upward-deviating maximum values and registry data is a trend toward better outcomes for the sublay technique demonstrated. Through the use of a wide mesh overlap, avoidance of dissection in the abdominal wall and defect closure it appears possible to achieve better outcomes for the open IPOM technique. Conclusion: Compared to the laparoscopic technique, open IPOM is associated with significantly poorer outcomes. For the sublay technique the outcomes are quite similar and only tendentially worse. Further studies using an optimized open IPOM technique are urgently needed.

IPOM: history of an acronym

IPOM has become a common term used by hernia surgeons. It refers to the treatment of a ventral hernia using an intraperitoneal placed mesh and most consider it an acronym for Intra-Peritoneal Onlay Mesh. Since intraperitoneal placement of mesh has fallen out of favor with some hernia surgeons and key-opinion-leaders recently, this might be the correct time to write down and preserve the history of this intriguing acronym.

What Is the Current Knowledge About Sublay/Retro-Rectus Repair of Incisional Hernias?

Introduction: There continues to be very little agreement among experts on the precise treatment strategy for incisional hernias. That is the conclusion drawn from the very limited scientific evidence available on the repair of incisional hernias. The present review now aims to critically assess the data available on the sublay/retro-rectus technique for repair of incisional hernia. Materials and Methods: A systematic search of the literature was performed in May 2018 using Medline, PubMed, and the Cochrane Library. This article is based on 77 publications. Results: The number of available RCTs that permit evaluation of the role of the sublay/retro-rectus technique in the repair of only incisional hernia is very small. The existing data suggest that the sublay/retro-rectus technique has disadvantages compared with the laparoscopic IPOM technique for repair of incisional hernia, but in that respect has advantages over all other open techniques. However, the few existing studies provide only a limited level of evidence for assessment purposes. Conclusion: Further RCTs based on a standardized technique are urgently needed for evaluation of the role of the sublay/retro-rectus incisional hernia repair technique.

Imaging complex ventral hernias, their surgical repair, and their complications

Abstract

Complex ventral hernia (CVH) describes large, anterior, ventral hernias. The incidence of CVH is rising rapidly due to increasing laparotomy rates in ever older, obese and co-morbid patients. Surgeons with a specific interest in CVH repair are now frequently referring these patients for imaging, normally computed tomography scanning. This review describes what information is required from preoperative imaging and the surgical options and techniques used for CVH repair, so that radiologists understand the postoperative appearances specific to CVH and are aware of the common complications following surgery.

Key Points

• Complex ventral hernia (CVH) describes large abdominal wall hernias (e.g. width ≥10cm).

• CVH patients are being referred increasingly for preoperative and postoperative imaging.

• Imaging is pivotal to characterise preoperative morphology and quantify loss of domain.

• Postoperative imaging appearances are contingent on the surgical methods used for CVH repair.

• Postoperative complications are depicted easily by imaging.