Prospective evaluation of adhesion characteristics to intraperitoneal mesh and adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair

Adhesions After Laparoscopic IPOM-How Serious Is the Problem?

Although laparoscopic IPOM is still the gold standard in ventral hernia repair, it is subject of a slow but constant decline, while new minimally invasive techniques are increasingly used, as well as open retromuscular repairs. One of the reasons are the intraperitoneal mesh position and its suspected higher risk for creating intraabdominal adhesions, compared to extraperitoneal mesh positions. In potential subsequent operations (e.g., in recurrent ventral hernia repair) adhesions usually must be taken down, which is a known risk factor for complications such as inadvertent enterotomies, surgical site infections and prolonged hospital stay. In this review we evaluate the incidence of intraabdominal adhesions after ventral hernia repair and their potential impact on surgical outcome in subsequent operations. Special attention is paid to the impact of mesh position in developing adhesions.

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.

Outcomes of subsequent abdominal operations after an initial ventral hernia repair

INTRODUCTION

Nearly 20% of ventral hernia repair (VHR) patients require a subsequent abdominal operation (SAO), and mesh position may impact the complexity and outcome of the SAO.

METHODS

Retrospective review of VHR with mesh from 2006 to 2020 from an internal database and the ACHQC. Primary outcomes measured incidence, complexity, and complications of SAO relative to mesh position.

RESULTS

SAO was required in 433 of 2539 (17.1%) patients, totaling 671 operations; 197/893 (22.1%) with intraperitoneal mesh (IPM) and 236/1646 (14.3%) with extraperitoneal mesh (EPM; p ​< ​0.001). SAO was directly related to VHR in 180 (232 total SAOs) and unrelated in 253 (439 total SAOs). There were no significant differences in complications after SAO between IPM and EPM, nor any difference in adhesion complexity.

CONCLUSION

Incidence of SAO is higher with IPM, but surgical outcomes are similar. Due to the risk of secondary mesh infection with IPM, significantly more of these were removed at the time of SAO.

Characterization and in vivo evaluation of a fabricated absorbable poly(vinyl alcohol)-based hernia mesh

The most widely taken medical approach toward hernia repair involves the implementation of a prosthetic mesh to cover the herniated site and reinforce the weakened area of the abdominal wall. Biodegradable meshes can serve as biocompatible grafts with a low risk of infection. However, their major complication is associated with a high rate of degradation and hernia recurrence. We proposed a facile and cost-effective method to fabricate a poly(vinyl alcohol)-based mesh, using the solution casting technique. The inclusion of zinc oxide nanoparticles, citric acid, and three cycles of freeze-thaw were intended to ameliorate the mechanical properties of poly(vinyl alcohol). Several characterization, cell culture, and animal studies were conducted. Swelling and water contact angle measurements confirmed good water uptake capacity and wetting behavior of the final mesh sample. The synthesized mesh acquired a high mechanical strength of 52.8 MPa, and its weight loss was decreased to 39 %. No cytotoxicity was found in all samples. In vivo experiments revealed that less adhesion and granuloma formation, greater tissue integration, and notably higher neovascularization rate were resulted from implanting this fabricated hernia mesh, compared to commercial Prolene® mesh. Furthermore, the amount of collagen deposition and influential growth factors were enhanced when rats were treated with the proposed mesh instead of Prolene®.

An improved approach of totally visceral sac separation (TVS) for incisional hernia compared with laparoscopic intraperitoneal onlay mesh plus repair (IPOM plus)

Endoscopic techniques have been widely used in ventral hernia surgery. Totally visceral sac separation (TVS) is a new concept proposed for hernia repair in recent years. The aim of this study was to contrast the postoperative results of TVS with the widely used method of Laparoscopic intraperitoneal onlay mesh plus repair (IPOM plus) for incisional hernias. The retrospective comparison analysis of 38 IPOM plus and 34 TVS was conducted during the time period between December 2019 and June 2022. For both two groups, baseline characteristics, surgical records, postoperative information, and quality of life outcomes utilizing the Carolina's Comfort Scale were collected and analyzed. There were no differences between the methods of TVS and IPOM plus among the baseline characteristics. It showed the operative time in TVS group with the mean time of 213.4 min was significantly longer than that in IPOM plus group with the mean time of 182.9 min (P = 0.010). The postoperative length of stay in TVS group was 6.2 days, which was significantly shorter than IPOM plus group with the mean time of 4.8 days (P = 0.011). The medical expenses was significantly smaller in TVS group than that in IPOM plus group (P < 0.001). The quality of life scores of TVS were significant better than IPOM plus at one week, one month and six months. Besides, both TVS and IPOM plus have very few complications. TVS approach for incisional hernias is secure, effective, and valuable. It has shorter postoperative length of stay, higher quality of life, longer operative time, smaller medical expenses, and approximate complications compared with IPOM plus procedure. Our results have a greater contribution to the application and popularization of TVS technique.

Experimental evaluation of the use of starch and carboxymethylcellulose in the prevention of intraperitoneal adhesions in hernia surgery with coated meshes

PURPOSE

Laparoscopic hernia repair involves a risk of adhesion between coated mesh and viscera. Plant polysaccharides such as starch and carboxymethylcellulose (SC) make up a product that acts as a barrier and prevents intraperitoneal adhesions. This study aimed to evaluate whether topical SC can also reduce adhesions between mesh and intra-abdominal organs.

METHODS

Forty rats each received placement of two intraperitoneal mesh fragments, one on each side of the abdominal wall. Randomly, 20 animals received SC on the right and other 20 on the left, leaving the contralateral side as a control. Fourteen days after the surgery, the animals underwent an additional laparotomy in which macroscopic analysis was performed.

RESULTS

As for the percentage of the mesh area affected by adhesion, one (2.6%) animal had > 75% adhesion on the experimental side, and 11 animals (28.9%) on the control side. The adhesion intensity score showed firm adhesions in three (7.9%) animals on the experimental side and nine (23.7%) on the control side.

CONCLUSIONS

The use of SC decreased the intensity of adhesions and the surface area of the mesh affected by adhesions. There was no negative interference of the product in the incorporation of the mesh into the abdominal wall.

Primary Ventral Hernia Repair and the Risk of Postoperative Small Bowel Obstruction: Intra Versus Extraperitoneal Mesh

OBJECTIVE

The aim of this study was to compare the likelihood of bowel obstruction according to the placement of the mesh (either intraperitoneal or extraperitoneal) in ventral hernia repairs.

MATERIALS AND METHODS

Patients were divided into two groups, an intraperitoneal (IP) group (mesh placed by laparoscopy or with an open approach) and an extraperitoneal (EP) group, all operated on in the Digestive Surgery Department at the Dijon University Hospital. The primary outcome was the occurrence of an episode of bowel obstruction requiring hospitalization and confirmed by abdominal CT scan.

RESULTS

Between March 2008 and July 2021, 318 patients were included, with 99 patients in the EP group (71 meshes placed preperitoneally and 28 placed retromuscularly) and 219 patients in the IP group (175 patients operated on laparoscopically versus 44 patients by direct approach). Three patients presented an episode of acute intestinal obstruction, with no difference between the two groups (p = 0.245), although all bowel obstructions occurred in the IP group and with the laparoscopic approach (1.7% of patients operated on by laparoscopy). The occlusive events occurred at 1 month, 2 years, and 3 years. There was no difference in terms of recurrence or postoperative chronic pain. There were more seroma and mesh infections in the EP group (p < 0.05). Two patients operated on by laparoscopy had undetected bowel injuries, prompting emergent surgery for peritonitis.

CONCLUSIONS

No statistically significant difference was found in terms of bowel obstruction between the intraperitoneal and the extraperitoneal position, but all cases of obstruction happened in the intraperitoneal mesh group. Visceral lesions remain a major complication of the laparoscopic approach that should not be neglected.

Efficacy of extended view totally extra peritoneal approach versus laparoscopic intraperitoneal on lay mesh plus for abdominal wall hernias: a single center preliminary retrospective study

BACKGROUND

Laparoscopic minimally invasive surgery has become the primary treatment for ventral hernias. The laparoscopic intraperitoneal on lay mesh (IPOM) plus approach for abdominal wall hernias is the most used procedure, while extended view totally extraperitoneal (e‑TEP) repair is a newer option. This study aimed to compare the effectiveness and complications of the 2 procedures for abdominal wall hernias repair.

METHODS

This was a retrospective and comparative single-center study done at The Second Clinical Medical College, Jinan University Hospital (Shenzhen People's Hospital), Shenzhen, China. The study included patients with a 2 to 6 cm abdominal wall defect who underwent hernia repair from January 2022 to December 2022. Patients' baseline characteristics, hernia features, operative time, blood loss, postoperative pain level, and total hospitalization expenses were extracted from the medical records and compared between patients who underwent the IPOM plus and e-TEP repair.

RESULTS

A total of 53 patients were included: 22 in the e-TEP group and 31 in IPOM plus group. Patient demographic characteristics were similar between the 2 groups. The operation time of the e-TEP groups was significantly longer than the IPOM plus (98.5 ± 10.7 min vs. 65.9 ± 7.3 min, P < 0.01). Postoperative pain levels (VAS; visual analog scale) (4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements (Tramadol) (25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay (1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and total hospitalization expenses (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01) were significantly lower in the e-TEP group. The mean intraoperative blood loss was similar between the 2 groups. No postoperative complications were observed in either group.

CONCLUSION

The e-TEP approach for abdominal wall hernias appears to be better than IPOM plus with respect to postoperative pain levels(VAS: 4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements(25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay(1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and hospitalization costs (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01).

Body Mass Index impact on Extended Total Extraperitoneal Ventral Hernia Repair: a comparative study

PURPOSE

Obesity is a risk factor for developing abdominal wall hernias and is associated with major postoperative complications, such as surgical site infection, delayed wound healing and recurrent hernia. Therefore, treating incisional hernia in this patient subgroup is a challenge.

METHODS

We conducted a comparative, prospective study on patients who underwent primary ventral hernia surgery or incisional hernia surgery through the extended totally extraperitoneal pathway, with body mass indices (BMIs) ≤ 30 (no obesity) and BMI > 30 (with obesity). We collected demographic data, preoperative and intraoperative variables, complication and recurrence rate, hospital stay and follow-up as postoperative data.

RESULTS

From May 2018 to December 2020, 74 patients underwent this surgery, 38 patients without obesity and 36 with obesity. The median area of the hernia defect measured by CT was 57 cm² and 93 cm² in patients without and with obesity, respectively (p = 0.012). The median follow-up was 16 months. One patient without obesity experienced some postoperative complication compared with four patients with obesity (p > 0.05). No patient without obesity had recurrent hernia compared with two patients with obesity (p > 0.05).

CONCLUSIONS

There were statistically significant differences between patients with and without obesity in the size of the hernia defect. However, there were no significant differences in terms of complications, hospital stay, postoperative pain or relapses. Therefore, the minimally invasive completely extraperitoneal approach for patients with obesity appears to be a safe procedure despite our study limitations. Studies with longer follow-ups and a greater number of patients are needed.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results

INTRODUCTION

Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation.

AIM

To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach.

METHODS

A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported.

RESULTS

66 patients were included in the study. Median follow-up was 22 months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12 years, 30 kg/m², 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9 cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%).

CONCLUSION

eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.

Experimental evaluation of intra-abdominal adhesions comparing two different intraperitoneal meshes and the effect of a natural anti-inflammatory product on their formation

Purpose:

In laparoscopic incisional hernia repair, meshes with a tissue-separating barrier are positioned intraperitoneally. Despite this property, the close contact between mesh and viscera involves a risk of adhesion formation. Some natural products, such as red propolis (RP), could reduce these adhesions owing to their anti-inflammatory properties. This study aimed to compare two different intraperitoneal meshes with respect to their characteristics of adhesion formation, histological findings and evaluate the role of RP in the development of these adhesions.

Methods:

40 Wistar rats received placement of two different meshes (Symbotex and Dynamesh IPOM) on peritoneum. The animals were divided into two groups: control group (mesh) and treatment group (mesh and RP). After 7 and 14 days, 20 animals of each group underwent midline laparotomy to determine the adhesions and histological characteristics.

Results:

Out of the 40 animals, there were two deaths in the test group and two in the control group. All animals in both groups developed adherence to the mesh. At postoperative day (POD) 7, two Symbotex meshes presented firm adhesions and at POD 14, two Dynamesh meshes had firm adhesions as well. The comparison between the meshes under the effect of RP in relation to the control group showed no statistical difference.

Conclusions:

Both meshes showed intraperitoneal adhesions in all evaluated samples with similar results on the characteristics of adhesions. RP showed no effect on the incidence or gradation of intraperitoneal adhesions with the mesh.

Second Look After Retromuscular Repair With the Combination of Absorbable and Permanent Meshes

Objective: The aim of this study is to describe the macroscopic features and histologic details observed after retromuscular abdominal wall reconstruction with the combination of an absorbable mesh and a permanent mesh.

Methods: We have considered all patients that underwent abdominal wall reconstruction (AWR) with the combination of two meshes that required to be reoperated for any reason. Data was extracted from a prospective multicenter study from 2012 to 2019. Macroscopic evaluation of parietal adhesions and histological analysis were carried out in this group of patients.

Results: Among 466 patients with AWR, we identified 26 patients that underwent a reoperation after abdominal wall reconstruction using absorbable and permanent mesh. In eight patients, the reoperation was related to abdominal wall issues: four patients were reoperated due to recurrence, three patients required an operation for chronic mesh infection and one patient for symptomatic bulging. A miscellanea of pathologies was the cause for reoperation in 18 patients. During the second surgical procedures made after a minimum of 3 months follow-up, a fibrous tissue between the permanent mesh covering and protecting the peritoneum was identified. This fibrous tissue facilitated blunt dissection between the permanent material and the peritoneum. Samples of this tissue were obtained for histological examination. No case of severe adhesions to the abdominal wall was seen. In four cases, the reoperation could be carried out laparoscopically with minimal adhesions from the previous procedure.

Conclusions: The reoperations performed after the combination of absorbable and permanent meshes have shown that the absorbable mesh acts as a protective barrier and is replaced by a fibrous layer rich in collagen. In the cases requiring new hernia repair, the layer between peritoneum and permanent mesh could be dissected without special difficulty. Few intraperitoneal adhesions to the abdominal wall were observed, mainly filmy, easy to detach, facilitating reoperations.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

[Existing and forward-looking ways to prevent adhesions in IPOM hernia repair. A research overview]

IPOM intraperitoneal hernia repair, in comparison with other abdominal wall reconstruction methods, has a number of significant advantages. Among them are a reduction in operative time, low rate of surgical site infections, quick rehabilitation, and good cosmetic results. At the same time, one of the main constraining factors for its widespread use is the rather high frequency of adhesion formation between the implant and the abdominal organs. The first way to solve this serious problem is to improve the structure of the implant itself, and in the first place, its anti-adhesive layer. The second is the search for adjuvant tools that work in «problematic» areas, prone to adhesions formation, such as the points of implant fixation, its edges, or the areas of damage to antiadhesive layer due to a violation of the operative technique. It is desirable that they could exert their effect also in other parts of the abdominal cavity, which, despite the absence of a zone of «active» intervention, can also undergo adhesions. Based on this, the purpose of this review was to summarize modern data on the anti-adhesive activity of both composite implants and specialized membranes and liquid agents.

Comparative study of four different types of intraperitoneal mesh prostheses in rats

Purpose:

To compare four types of mesh regarding visceral adhesions, inflammatory response and incorporation.

Methods:

Sixty Wistar rats were divided into four groups, with different meshes implanted intraperitoneally: polytetrafluoroethylene (ePTFE group); polypropylene with polydioxanone and oxidized cellulose (PCD); polypropylene (PM) and polypropylene with silicone (PMS). The variables analyzed were: area covered by adhesions, incorporation of the mesh and inflammatory reaction (evaluated histologically and by COX2 immunochemistry).

Results:

The PMS group had the lowest adhesion area (63.1%) and grade 1 adhesions. The ePTFE and PM groups presented almost the total area of their surface covered by adherences (99.8% and 97.7% respectively) The group ePTFE had the highest percentage of area without incorporation (42%; p <0.001) with no difference between the other meshes. The PMS group had the best incorporation rate. And the histological analysis revealed that the inflammation scores were significantly different.

Conclusions:

The PM mesh had higher density of adherences, larger area of adherences, adherences to organs and percentage of incorporation. ePTFE had the higher area of adherences and lower incorporation. The PMS mesh performed best in the inflammation score, had a higher incorporation and lower area of adherences, and it was considered the best type of mesh.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluating full-thickness skin grafts in intraperitoneal onlay mesh position versus onlay position in mice

BACKGROUND

Importance: Hernia surgery requires reinforcement material with few side effects when used in the intraperitoneal position. Autologous skin grafting may meet this requirement, but animal experiments are obligatory before being applied in humans.

OBJECTIVE

To compare survival and effects of isogeneic full-thickness skin grafts in the intraperitoneal onlay mesh (IPOM) position in mice, with a control group using the onlay position. Primary end point was graft survival and secondary end point adhesion formation and inflammation through NF-κB activity.

METHODS

Design: Intervention study with 8-week follow-up in accordance with ARRIVE criteria, performed between 2015 and 2016.

SETTING

Animal laboratory.

PARTICIPANTS

Transgenic C57BL/6 mice with isogeneic background were used. Recipients were female wild-type phenotype mice >3 mo (n = 24). Donors were male or female mice >7 mo, with phenotype-positive for the luciferase gene (n = 20) or positive for NF-κB-luciferase gene (n = 4).

INTERVENTION

Full-thickness skin was grafted in the IPOM position and compared with grafts in the onlay position as controls. Survival was evaluated by regular longitudinal postoperative luminescence imaging over 8 wk. Adherence formation was evaluated macroscopically after sacrifice. Inflammation of full-thickness skin grafts in IPOM position of NF-κB mice was evaluated in four additional mice. Main outcome and measure: Survival of grafts, evaluated by luminescence.

RESULTS

Ten animals received grafts in the IPOM position, and 10 in the onlay position as controls. Graft survival after 8 wk was 100% (20/20). Average luminescence at the end of the 8-week period was 999,597 flux (min 162,800, max 2,521,530) in the IPOM group (n = 10) and 769,708 flux (min 76,590, max 2,164,080) in the onlay control group (n = 10). No adhesions requiring sharp dissection (Jenkins' scale >2) were seen. Four animals with grafts in the IPOM position showed peak inflammation (NF-κB activity) 5 d after surgery subsiding toward the end of follow-up.

CONCLUSIONS

Full-thickness skin survives as well in the IPOM position as in the onlay control position, and few adherences develop. Further studies are required to fully characterize the tissue remodeling and repair processes associated with IPOM skin grafting. The result is relevant in the search for alternative reinforcement materials to be used in complex hernia surgery in humans.

Liquid antiadhesive agents for intraperitoneal hernia repair procedures: Artiss® compared to CoSeal® and Adept® in an IPOM rat model

BACKGROUND

Adhesion formation remains an important issue in hernia surgery. Liquid agents were developed for easy and versatile application, especially in laparoscopy. The aim of this study was to compare the antiadhesive effect of fibrin sealant (FS, Artiss^®), Icodextrin (ID, Adept^®) and Polyethylene glycol (PEG, CoSeal^®) alone and in combination and to evaluate the resulting effect on tissue integration of the mesh.

METHODS

A total of 56 Sprague-Dawley rats were operated in open IPOM technique. A middleweight polypropylene mesh of 2 × 2 cm size was implanted and covered with 1: FS, 2: ID, 3: PEG, 4: FS + ID, 5: FS + PEG, 6: PEG + ID, 7: control group, uncovered mesh (n = 8 per treatment/control). Observation period was 30 days. Macroscopic and histological evaluation was performed.

RESULTS

Severe adhesions were found in group 2 (ID), group 6 (PEG + ID) and the controls. Best results were achieved with FS alone or FS + ID. Mesh integration in the treatment groups was reduced in comparison with the control group. This is a new finding possibly relevant for the outcome of intraperitoneal mesh repair. Group 6 (PEG + ID) showed an impairment of tissue integration with <50 % of the mesh surface in seven samples.

CONCLUSION

FS alone and in combination with ID yielded excellent adhesion prevention. ID alone did not show significant adhesion prevention after 30 days. Tissue integration of FS-covered meshes was superior to ID or PEG alone or combined. PEG did show adhesion prevention comparable to FS but evoked impaired tissue integration. So Artiss^® is among the most potent antiadhesive agents in IPOM repair.

Outcomes of bridging versus mesh augmentation in laparoscopic repair of small and medium midline ventral hernias

BACKGROUND

Bridging of the hernia defect in laparoscopic repair (sIPOM) technique does not fully restore the abdominal wall function. Closure of hernia defect in IPOM-plus technique leads to the restoration of abdominal wall function and improved long-term treatment outcomes. Against the expectations, the studies confirm the formation of intraabdominal adhesions to the mesh. Regardless of the above, the search of the proper technique for mesh implantation and fixation is still ongoing. There have also been attempts to identify groups of patients who may still benefit from IPOM procedure.

MATERIALS AND METHODS

Patients with midline abdominal wall hernias up to 10 cm wide were enrolled in the study except for subxiphoid and suprapubic hernias. Between 2011 and 2014 we performed 82 hernia repairs using the laparoscopic technique with Physiomesh. Patients were divided into sIPOM and IPOM-plus groups. The study included 44M and 38F patients aged 27-84 years. After 12-months and again in August 2015 a survey was posted to all patients with questions regarding potential recurrence.

RESULTS

After 12 months, eight patients (20 %) in sIPOM group reported subjectively perceived recurrence and none in IPOM-plus group (p = 0.002). Six patients (14.3 %) in sIPOM group reported suspected recurrence, as compared to three patients (7.1 %) in IPOM-plus group (p = 0.13). These patients were invited for a follow-up physical examination and sonography. Eventually, four cases of hernia recurrence were confirmed in sIPOM group (10 %) and none in IPOM-plus group (p = 0.018). Other patients presented with mesh bulging.

CONCLUSIONS

Laparoscopic ventral hernia repair is generally safe and is associated with the low recurrence rate. Closure of fascial defects before mesh insertion offers better treatment outcomes. Non-closure of fascial defects with only bridging of the hernia defect (sIPOM) causes more frequent recurrence and bulging. As a result, patient satisfaction with treatment is lower, and they are concerned about hernia recurrence.

Inflammatory reaction to fish oil coated polypropylene mesh used for laparoscopic incisional hernia repair: a case report

Background

Polypropylene meshes are widely used in hernia repairs. Hernia meshes have been developed incorporating coatings of active agents. One commercially available mesh has a fish oil coating which is promoted as having anti-inflammatory properties. We report a case, a symptomatic foreign body granuloma reaction associated with a fish oil coated polypropylene mesh, which required eventual mesh explantation.

Case presentation

A 61-year old lady with previous peptic ulcer disease underwent a laparoscopic intraperitoneal placement of mesh for incisional hernia utilising a fish oil coated polypropylene mesh. The patient presented 3 months after the procedure complaining of dyspepsia and pain at the operative site. There was no discharge. The patient was managed conservatively. She presented 10 months post-operatively with progressively worsening symptoms and a hard palpable mass in the epigastrium. Abdominal laparoscopy revealed dense adhesive disease around the mesh with exudates. Adhesiolysis, mesh explantation and a partial gastrectomy was performed. Histopathological examination revealed a foreign body granuloma formation to the mesh.

Conclusion

In-vivo studies looking at intraperitoneal mesh placement with fish oil coatings including data on surgical outcomes such as fistula and adhesive characteristics are scarce in the literature. Further monitoring and studies are required to investigate the safety and efficacy profile of this mesh type in in-vivo models.

Outcomes of 157 V-Patch™ Implants in the Repair of Umbilical, Epigastric, and Incisional Hernias

Umbilical, epigastric, and incisional hernias have traditionally been repaired using a Mayo or tensioned suture technique, with recurrence rates of approximately 50 per cent. Recent studies have shown that a tension-free repair using mesh can drastically decrease recurrence rates. Reinforced deployment prostheses are preferred because they enable retrofascial placement through a small incision, thus avoiding the potential morbidity of a larger incision and the costs associated with a laparoscopic approach. A retrospective chart review was performed of all umbilical, epigastric and incisional hernias repaired with V-Patch, a reinforced deployment prosthesis, by a single surgeon. Data analysis included patient characteristics, operative and postoperative metrics, hernia recurrence, and complication rates. Between 2009 and 2012, 157 implantations were performed in 152 patients during 156 procedures. Patient age ranged from 20 to 85 (mean 48). There were 88 females (57.9%) and 64 males (42.1%) with average body mass index of 30.6. Patch size distribution was 78 small (49.7%), 55 medium (35.0%), and 24 large (15.3%). There were 81 umbilical hernias (51.6%), 36 epigastric hernias (22.9%), 39 incisional hernias (24.8%), and 1 multiple recurrent inguinal hernia (0.6%) repaired. Follow-up time ranged from 18 months to 4.3 years. There were six hernia recurrences (3.2%). Complications included three patients (1.9%) with mesh infection, one with an enterocutaneous fistula (0.6%), and one patient with a postoperative small bowel obstruction (0.6%). Four patients required patch explantation (2.5%). The V-Patch reinforced deployment prosthesis is effective in the treatment of umbilical, epigastric, and incisional hernias, and has a low rate of complications.

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20^th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4^th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]

BACKGROUND

The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues.

METHODS

The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group.

RESULTS AND CONCLUSIONS

The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.

Biomechanical abdominal wall model applied to hernia repair

BACKGROUND

Most surgical innovations require extensive preclinical testing before employment in the operative environment. There is currently no way to develop and test innovations for abdominal wall surgery that is cheap, repeatable and easy to use. In hernia repair, the required mesh overlap relative to defect size is not established. The aims of this study were to develop a biomechanical model of the abdominal wall based on in vivo pressure measurements, and to apply this to study mesh overlap in hernia repair.

METHODS

An observational study of intra-abdominal pressure (IAP) levels throughout abdominal surgery was conducted to identify the peak perioperative IAP in vivo. This was then applied in the development of a surrogate abdominal wall model. An in vitro study of mesh overlap for various defect sizes was then conducted using this clinically relevant surrogate abdomen model.

RESULTS

The mean peak perioperative IAP recorded in the clinical study was 1740 Pa, and occurred during awakening from anaesthesia. This was reproduced in the surrogate abdomen model, which was also able to replicate incisional hernia formation. Using this model, the mesh overlap necessary to prevent hernia formation up to 20 kPa was found, independent of anatomical variations, to be 2 × (defect diameter) + 25 mm.

CONCLUSION

This study demonstrated that a surgically relevant surrogate abdominal wall model is a useful translational tool in the study of hernia repair. Surgical relevance This study examined the mesh overlap requirements for hernia repair, evaluated in a biomechanical model of the abdomen. Currently, mesh size is selected based on empirical evidence and may underpredict the requirement for large meshes. The study proposes a relationship between the defect size and mesh size to select the appropriate mesh size. Following further trials and investigations, this could be used in clinical practice to reduce the incidence of hernia recurrence.

Laparoscopic repair of incisional and ventral hernias with the new type of meshes: randomized control trial

Introduction

Laparoscopic incisional and ventral hernia repair (LIVHR) was first reported by Le Blanc and Booth in 1993. Many studies are available in the literature that have shown that laparoscopic repair of incisional and ventral hernia is preferred over open repair because of lower recurrence rates (less than 10%), less wound morbidity, less pain, and early return to work.

Aim

To identify the long-term outcomes between the different types of meshes and two techniques of mesh fixation, i.e., tacks (method Double crown) and transfascial polypropylene sutures.

Material and methods

A total of 92 patients underwent LIVHR at our department between January 2009 and August 2012. The hernias were umbilical in 26 patients, paraumbilical in 15 patients and incisional in 51 patients. All patients admitted for LIVHR were randomized to either group I (tacker fixation of ePTFE meshes) or group II (suture fixation of meshes with nitinol frame) using computer-generated random numbers with block randomization and sealed envelopes for concealed allocation.

Results

The mean mesh fixation time was significantly higher in the tacker fixation group (117 ±15 min vs. 72 ±6 min, p < 0.01). There were no conversions in either group. The median postoperative hospital stay was 3.5 ±1.5 days. All patients were followed up at 1, 3, 6, 12 and every 6 months thereafter postoperatively. There were 5 recurrences in the study population. In group I there were 4 patients with recurrence, and only 1 patient in the group with meshes with a nitinol frame.

Conclusions

Meshes of the new generation with a nitinol framework can significantly improve laparoscopic ventral hernia repair. The fixation of these meshes is very simple using 3–4 transfascial sutures. The absence of shrinkage of these meshes makes the probability of recurrence minimal. Absence of tackers allows postoperative pain to be minimized. We consider that these new meshes can significantly improve laparoscopic ventral hernia repair.

Concomitant sublay mesh repair of umbilical hernia and abdominoplasty

Concomitant mesh repair of large umbilical hernias and abdominoplasty pose a serious risk of devascularizing the umbilical stalk. A technique of placing mesh in a sublay manner, deep to the fascial defect, for an umbilical herniorrhaphy to avoid damage to the deep umbilical perforators during an abdominoplasty is described.

Ventralight ST and SorbaFix versus Physiomesh and Securestrap in a porcine model

BACKGROUND AND OBJECTIVES

The objective of this study was to compare mesh contracture, adhesion characteristics, tissue ingrowth, and histologic response of Ventralight ST/SorbaFix (C.R. Bard/Davol, Warwick, RI, USA) with Physiomesh/Securestrap (Ethicon, Somerville, NJ, USA) in a porcine model of laparoscopic ventral hernia repair.

METHODS

Standard laparoscopic technique was used to bilaterally implant meshes in 10 female Yorkshire swine. Each animal received either two Ventralight ST meshes (oval shaped, 10.2 × 15.2 cm) or two Physiomesh meshes (oval shaped 10 × 15 cm), one on either side of the midline. The meshes were fixated to the intact peritoneum with either SorbaFix (for animals receiving Ventralight ST) or Securestrap (for animals receiving Physiomesh). There were 5 animals in each group, yielding 10 of each meshfixation combination. Mesh contracture, adhesion characteristics, tissue ingrowth, and histologic response were evaluated after 14 days by image analysis, mechanical testing, and histologic staining (hematoxylin-eosin, Masson trichrome, picrosirius red, and von Willebrand factor).

RESULTS

Ventralight ST/SorbaFix and Physiomesh/Securestrap exhibited a similar percentage of mesh contracture, percentage of adhesion coverage, adhesion tenacity, collagen deposition, and levels of necrosis (P > .05 in all cases). However, Ventralight ST/SorbaFix exhibited significantly less inflammation (P = .0001), fibrosis (P = .0017), hemorrhage (P = .0001), and angiogenesis (P = .0032) and significantly greater strength of tissue ingrowth (P = .0003) than Physiomesh/Securestrap after the 14-day implantation period.

CONCLUSIONS

Ventralight ST/SorbaFix exhibited more favorable strength of tissue ingrowth and histologic response and similar mesh contracture and adhesion characteristics compared with Physiomesh/Securestrap over a short-term 14-day implantation period in a preclinical porcine model.

Cost-benefit analysis comparing laparoscopic and open ventral hernia repair

OBJECTIVE

Laparoscopic surgery is a successful treatment option offering significant advantages to patients compared with open ventral hernia repair. A cost-benefit analysis was performed to compare the clinical results and economic costs of the open and laparoscopic techniques for anterior abdominal wall hernia repair, in order to determine the more efficient procedure.

MATERIAL AND METHODS

We performed a prospective study of 140 patients with primary and incisional hernia, and analyzed clinical data, morbidity, costs of surgery and hospital stay costs.

RESULTS

The cost of disposable surgical supplies was higher with laparoscopic repair but reduced the average length of stay (P<.001) and patient morbidity (P<.001). The total cost of the laparoscopic procedure was, therefore, less than initially estimated, yielding a savings of 1,260€ per patient (2,865€ vs. 4,125€).

CONCLUSIONS

Laparoscopic ventral hernia repair is associated with a reduced complication rate, a lower average length of stay and with lower total costs. Laparoscopic repair can save 1.260€ for each patient, and so this procedure should be considered a cost-effective approach.

Coated meshes for hernia repair provide comparable intraperitoneal adhesion prevention

BACKGROUND

Laparoscopic incisional hernia repair with intraperitoneal mesh is associated with a certain degree of adhesion formation to the mesh. This experimental study examined the efficacy of several coated meshes for adhesion reduction.

METHODS

Five commercially available meshes with a layered coating were placed intraperitoneally in rats and followed up for 90 days: polypropylene and polyester meshes, both coated with absorbable collagen (Parietene Composite and Parietex Composite, respectively), and three polypropylene meshes respectively coated with absorbable omega-3 fatty acids (C-Qur Edge), absorbable cellulose (Sepramesh IP), and nonabsorbable expanded polytetrafluoroethylene (Intramesh T1). Uncoated polypropylene and collagen meshs (Parietene and Permacol, respectively) served as the control condition. Adhesions, incorporation, and tissue reaction were evaluated macro- and microscopically. Additionally, the development of the neoperitoneum was examined.

RESULTS

All the coated meshes performed equally well in terms of adhesion reduction. The collagen mesh performed comparably, but the uncoated polypropylene mesh performed significantly worse. The different coatings led to very differing degrees of inflammation. Ingrowth was observed only at the place of suture but was comparable for all the meshes except C-Qur Edge, which showed the weakest incorporation. Development of a neoperitoneum on the mesh surface occurred independently of whether an absorbable or nonabsorbable coating or no coating at all was present.

CONCLUSIONS

Commercially available meshes with a layered coating deliver comparable adhesion reduction. The physical presence of a layered coating between the intraperitoneal content and the abdominal wall seems to be more important than the chemical properties of the coating in adhesion formation.

DynaMesh® in the repair of laparoscopic ventral hernia: a prospective trial

PURPOSE

To investigate mesh-related complications in patients undergoing laparoscopic ventral hernia repair using DynaMesh®.

METHODS

In the period 1 January 2005 through 31 December 2010, 181 consecutive patients undergoing laparoscopic ventral hernia repair in our day surgery unit using DynaMesh® were entered prospectively in the National Danish Hernia Database. Data concerning abdominal reoperations after hernia repair were later collected on all 181 patients from the National Danish Health Registry. Postoperative telephone interviews were conducted estimating postoperative pain and patient satisfaction.

RESULTS

Six % (11 patients) were reoperated because of mesh-related complications. Three had small bowel obstruction and one had a colonic fistula with mesh infection, all causing bowel resection and mesh removal. Mesh-related cutaneous fistula was seen in one patient. Six patients had a symptomatic recurrence requiring reoperation. Abdominal wall hematomas were seen in two cases, while two other patients had symptomatic large seromas, of which one was drained surgically. After a median follow-up of 34 months (range 12-63) in 140 patients, 66 % were pain free (0 on the Numeric Rating Scale (NRS)). Of 26 patients with moderate to severe pain (NRS > 3) at follow-up, only 4 regretted the operation. Sixteen patients thought they had a recurrence, of these only 3 regretted the operation.

CONCLUSION

The use of DynaMesh® in laparoscopic ventral hernia repair was associated with a 6 % risk of mesh-related reoperation in a high volume setting. Despite chronic pain in 19 %, after 34 months follow-up patient satisfaction was high.

Outcomes of a prospective multi-center trial of a second-generation composite mesh for open ventral hernia repair

PURPOSE

Composite mesh prostheses incorporate properties of multiple materials for use in open ventral hernia repair (OVHR). This study examines clinical outcomes in patients who underwent OVHR with a polypropylene/expanded polytetrafluoroethylene (ePTFE) composite graft containing a novel polydioxanone (PDO) absorbable ring to facilitate placement and graft positioning.

METHODS

Data were prospectively collected on consecutive patients undergoing OVHR using a synthetic composite mesh. Seven centers enrolled patients during the study period. All patients underwent a standardized surgical procedure consisting of OVHR with sublay intraperitoneal placement of mesh. Mesh fixation was accomplished with peripheral tacks and transfascial sutures.

RESULTS

One hundred and nineteen patients underwent OVHR with the composite mesh. Average age was 55.8 years; there were 71 (59.7 %) females and 48 (40.3 %) males with mean BMI of 33.5 ± 7.1 kg/m(2). One hundred and two (85.7 %) patients presented with primary ventral hernias. Mean defect size was 13.6 cm(2), and mean mesh size was 113.6 cm(2). Most patients (67 %) were discharged the day of surgery. Twelve patients (10.1 %) experienced complications in the perioperative time period primarily consisting of seroma (4.2 %) and ileus (1.7 %). Two patients required reoperation and mesh removal in the early postoperative period for infection and herniorrhaphy site pain, respectively. There was a decline in pain and movement limitation scores between baseline and 1-year follow-up. Six-month (n = 109) and twelve-month (n = 99) follow-up revealed no hernia recurrences (95 % CI 0-3 %, and 0-4 %, respectively).

CONCLUSIONS

The use of this second-generation composite mesh was associated with no hernia recurrences and a low complication rate after open ventral hernia repair.

Experimental study on synthetic and biological mesh implantation in a contaminated environment

BACKGROUND

Implantation of meshes in a contaminated environment can be complicated by mesh infection and adhesion formation.

METHODS

The caecal ligation and puncture model was used to induce peritonitis in 144 rats. Seven commercially available meshes were implanted intraperitoneally: six non-absorbable meshes, of which three had an absorbable coating, and one biological mesh. Mesh infection, intra-abdominal abscess formation, adhesion formation, incorporation and shrinkage were evaluated after 28 and 90 days. Histological examination with haematoxylin and eosin and picrosirius red staining was performed.

RESULTS

No mesh infections occurred in Sepramesh(®) , Omyramesh(®) and Strattice(®) . One mesh infection occurred in Parietene(®) and Parietene Composite(®) . Significantly more mesh infections were found in C-Qur(®) (15 of 16; P ≤ 0·006) and Dualmesh(®) (7 of 15; P ≤ 0·035). Sepramesh(®) showed a significant increase in adhesion coverage from 12·5 per cent at 28 days to 60·0 per cent at 90 days (P = 0·010). At 90 days there was no significant difference between median adhesion coverage of Parietene Composite(®) (35·0 per cent), Omyramesh(®) (42·5 per cent), Sepramesh(®) (60·0 per cent) and Parietene(®) (72·5 per cent). After 90 days the adhesion coverage of Strattice(®) was 5·0 per cent, and incorporation (13·4 per cent) was significantly poorer than for other non-infected meshes (P ≤ 0·009). Dualmesh(®) showed shrinkage of 63 per cent after 90 days.

CONCLUSION

Parietene Composite(®) and Omyramesh(®) performed well in a contaminated environment. Strattice(®) had little adhesion formation and no mesh infection, but poor incorporation. Some synthetic meshes can be as resistant to infection as biological meshes.

Strategies to minimize adhesions to intraperitoneally placed mesh in laparoscopic ventral hernia repair

INTRODUCTION

Adhesions to mesh/tacks in laparoscopic ventral hernia repair are often cited as reasons not to adopt its evidence-based superiority over conventional open methods. This pilot study assessed the occurrence of adhesions to full-sized Polypropylene and Gore-tex DualMesh Plus meshes and the possibility for adhesion prevention using fibrin sealant.

METHODS

Two 10-cm to 15-cm pieces of mesh were placed and fixed laparoscopically in pigs (25kg to 55kg). Group I: 2 animals with Polypropylene mesh on one side and DualMesh on other side. Group II: 2 animals with DualMesh on each side with fibrin sealant applied to the periphery of mesh and staples to one side. Group III: 1 animal with 2 pieces of Polypropylene mesh with fibrin sealant applied to the entire mesh. All animals underwent laparoscopy 3 months later to assess the extent of adhesions, and full-thickness specimens were removed for histological evaluation.

RESULTS

More Polypropylene mesh was involved in adhesions than DualMesh. However, with the DualMesh involved in adhesions, more of the surface area was involved in forming adhesions than with Polypropylene mesh. None of the implanted DualMesh had visceral adhesions, while 2 out of 3 Polypropylene meshes had adhesions to both the liver and spleen but none to the bowel. Implanted Polypropylene mesh with fibrin sealant had no adhesions. DualMesh had shrunk more significantly than Polypropylene mesh. Histological evaluation showed absence of acute inflammatory response, significantly more chronic inflammatory response to DualMesh compared to Polypropylene and complete mesothelialization with both meshes. There was extensive collagen deposition between Polypropylene mesh fibers, while fibrosis occurred on both sides of DualMesh with synovial metaplasia over its peritoneal surface akin to encapsulation.

CONCLUSIONS

DualMesh caused fewer omental and visceral adhesions than Polypropylene mesh did. Fibrin sealant eliminated adhesions to DualMesh and prevented adhesions to Polypropylene mesh when applied over the entire surface. These results support our current use of DualMesh and fibrin sealant in LVHR.

Repair of incisional hernias with biological prosthesis: a systematic review of current evidence

BACKGROUND

No consensus has been reached on the use of bioprosthetics to repair abdominal wall defects. The purpose of this systematic review was to summarize the outcomes from studies describing this use of various bioprosthetics for incisional hernia repair.

METHODS

Studies published by October 2011 were identified through literature searches using EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials.

RESULTS

A total of 491 articles were scanned, 60 met eligibility criteria. Most studies were retrospective case studies. The studies ranged considerably in methodologic quality, with a modified Methodological Index of Nonrandomized Studies score from 5 to 12. Many repairs were performed in contaminated surgical sites (47.9%). At least one complication was seen in 87% of repairs. Major complications noted were wound infections (16.9%) and seroma (12.0%). With a mean follow-up period of 13.6 months the hernia recurrence rate was 15.2%.

CONCLUSIONS

There is an insufficient level of high-quality evidence in the literature on the value of bioprosthetics for incisional hernia repair. Randomized controlled trials that use standardized reporting comparing bioprosthetics with synthetic mesh for incisional hernia repair are needed.

In vivo MRI visualization of mesh shrinkage using surgical implants loaded with superparamagnetic iron oxides

BACKGROUND

Prosthetic mesh implants are widely used in hernia surgery. To show long-term mesh-related complications such as shrinkage or adhesions, a precise visualization of meshes and their vicinity in vivo is important. By supplementing mesh fibers with ferro particles, magnetic resonance imaging (MRI) can help to delineate the mesh itself. This study aimed to demonstrate and quantify time-dependent mesh shrinkage in vivo by MRI.

METHODS

Polyvinylidenfluoride (PVDF) meshes with incorporated superparamagnetic iron oxides (SPIOs) were implanted as an abdominal wall replacement in 30 rats. On days 1, 7, 14, or 21, MRI was performed using a gradient echo sequence with repetition time (TR)/echo time (TE) of 50/4.6 and a flip angle of 20°. The length, width, and area of the device were measured on axial, coronal, and sagittal images, and geometric deformations were assessed by surgical explantation.

RESULTS

In all cases, the meshes were visualized and their area estimated by measuring the length and width of the mesh. The MRI presented a mean area shrinkage in vivo of 13% on day 7, 23% on day 14, and 23% on day 21. Postmortem measurements differed statistically from MRI, with a mean area shrinkage of 23% on day 7, 28% on day 14, and 30% on day 21. Ex vivo measurements of shrinkage showed in vivo measurements to be overestimated approximately 8%. Delineation of the mesh helped to show folding or adhesions close to the intestine.

CONCLUSION

Loading of surgical meshes with SPIOs allows their precise visualization during MRI and guarantees an accurate in vivo assessment of their shrinkage. The authors' observation clearly indicates that shrinkage in vivo is remarkably less than that shown by illustrated explantation measurements. The use of MRI with such meshes could be a reliable technique for checking on proper operation of implanted meshes and showing related complications, obviating the need for exploratory open surgical revision.

Laparoscopic transabdominal preperitoneal repair of ventral hernia: a step towards physiological repair

The laparoscopic ventral hernia repair with preperitoneal placement of mesh minimizes the complications related to the intraperitoneal position of mesh and fixating devices. It allows safe use of conventional and less expensive polypropylene mesh. The prospectively collected data of 68 patients who underwent laparoscopic transabdominal preperitoneal mesh hernioplasty, for different types of ventral hernias between January 2005 and December 2009 was retrospectively reviewed. The study included 68 patients, 16 males and 52 females with a mean age 51.1 ± 11.1 years (range 23-74 years). Most of the hernias (67.6%) were in the midline position. The mean size of the defect was 30.8 ± 24.4 cm2 (range, 4-144 cm2) and the mean mesh size was 237.8 ± 66.8 cm2 (range, 144-484 cm2). The mean operating time was 96.7 ± 16.7 min (range 70-150 min). All repairs were done with polypropylene mesh. The mean postoperative hospital stay was 1.5 ± 0.6 days (range, 1-4 days). Nineteen patients (27.9%) suffered from postoperative complications. Four patients (5.8%) were detected to have seroma formation. There were two recurrences (2.9%). The mean follow up was 22.7 ± 13.4 months (range, 6-48 months). The laparoscopic preperitoneal ventral hernia repair with polypropylene mesh is cheaper and has acceptable postoperative outcomes. Peritoneal coverage of the mesh not only acts as a barrier between mesh and bowel and thereby prevents adhesions, it also provides an additional security of fixation. This is a safe and feasible option of ventral hernia repair in expert hands. However, for proper validation of these conclusions a long term prospective clinical trial is required.