Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh

Prospective, observational study of intraperitoneal onlay mesh repair with defect closure versus SCOLA for primary ventral hernia

INTRODUCTION

The last decade has witnessed several modifications in the laparoscopic techniques for ventral hernia. The aim of this study was to compare an established repair such as laparoscopic intraperitoneal onlay mesh repair with defect closure (IPOM plus) with subcutaneous onlay endoscopic approach (SCOLA) for medium ventral hernia.

PATIENTS AND METHODS

From June 2019 to November 2021, 29 patients undergoing IPOM plus and 22 patients undergoing SCOLA for medium ventral hernia (umbilical and epigastric hernia of size 2-4 cm) were included in the study. A comparative analysis was performed in terms of surgical outcomes and post-operative pain.

RESULTS

The two groups were comparable in terms of age and body mass index. The mean operation time of the SCOLA group was higher but not statistically significant. The Visual Analogue Scale score for pain after IPOM plus was significantly higher on post-operative day 1, at discharge and on the first follow-up visit. Around 45.4% of patients in the SCOLA group were discharged with the drain in situ which was later removed on the outpatient visit. However, no drains were placed in the IPOM plus group. The rate of seroma formation was 10.34% in the IPOM plus group and 27.27% in the SCOLA group. The material cost of IPOM plus procedure was significantly higher than that of the SCOLA. At the end of 1 year, there was no recurrence in either group.

CONCLUSION

Our study showed that the post-operative pain after SCOLA is significantly less compared to IPOM plus. SCOLA is feasible for medium midline ventral hernia. However, a study with larger sample size and longer follow-up is warranted to compare the operative morbidity of the two procedures.

A randomized controlled trial on the effectiveness of laparoscopic-guided transversus abdominis plane block in patients undergoing laparoscopic IPOM plus

INTRODUCTION

Ventral hernia repairs, particularly laparoscopic ventral hernia repair (LVHR), have become common procedures among general surgeons worldwide. Despite the benefits of LVHR, acute postoperative pain remains a significant concern. Transversus abdominis plane (TAP) blocks have been employed to alleviate postoperative pain in various laparoscopic procedures. This study aimed to assess the effectiveness of laparoscopic-guided TAP block in laparoscopic IPOM plus and its impact on postoperative pain and analgesic requirements.

MATERIALS AND METHODS

A randomized controlled trial was conducted at a tertiary care center in India involving 72 patients undergoing laparoscopic IPOM plus. Patients were randomized into two groups: Group I received laparoscopic-guided TAP block, while Group II received standard general anesthesia without TAP block. Pain scores were assessed at 6, 12, and 24 h postoperatively using the numerical rating scale. Postoperative analgesic requirements were also recorded.

RESULTS

Group I demonstrated significantly lower pain scores at 6 and 24 h postoperatively compared to Group II. The need for additional analgesics was significantly lower in Group I (13.8%) compared to Group II (72.2%). There were no significant differences in age, BMI, duration of surgery, or other demographic characteristics between the two groups.

CONCLUSION

The findings of this randomized controlled trial demonstrate the effectiveness of laparoscopic-guided TAP blocks in reducing postoperative pain and analgesic requirements after laparoscopic IPOM plus.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic treatment of ventral hernias: the Italian national guidelines

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

A prospective randomized controlled study to compare the efficacy and safety of barbed sutures versus standard fixation techniques using tackers in laparoscopic ventral and incisional hernia repair

Background

Laparoscopic ventral and incisional hernia mesh repair (LVIHR) has become the standard of care due to shorter recovery time, low rate of complication and recurrence. The most common fixation technique for mesh is by tackers but results in patients having more pain in the early postoperative period. One modality to reduce pain has been to use intracorporeal conventional sutures but with the disadvantage of inherent difficulty in handling, suturing and knotting which is obviated by barbed sutures.

Methods

The study was conducted over a period of two years. Sixty patients with primary ventral and incisional hernia were randomized to either fixation of mesh with barbed sutures or to tackers with transfacial sutures. Primary end points were used to evaluate and compare mesh fixation time, early postoperative pain and complications, whereas secondary end points were used to compare the incidence of chronic pain and recurrence.

Results

Of the 60 patients, 51% had primary ventral hernia, and the rest had incisional hernia. Visual Analogue Scale (VAS) pain score for the barbed suture group at all intervals postoperatively was significantly lower than that for tackers. The mean time taken for fixation in the tacker group was significantly lower. Only one patient under the tacker group developed recurrence.

Conclusion

Barbed suture group had significantly less pain and is economical with the same rates of recurrence as compared with tackers. Hence, low pain scores, cost effectiveness and relatively easier intracorporeal suturing make barbed sutures a viable alternative for intracorporeal mesh fixation in LVIHR.

Laproscopic versus open ventral hernia repair

Background: Ventral hernia is second most common type of abdominal hernia after inguinal hernia. Treatment includes anatomical repair, meshplasty: onlay, sublay, preperitoneal etc. Evaluation of laparoscopic hernia repair has led to new benchmark for ventral hernia repair. This study aims to compare laparoscopic ventral hernia repair versus open repair. Methods: Total 30 patients were enrolled in this study who presented to Dhiraj hospital pipariya. Detailed history was taken and patient were randomly divided in to 2 groups. Results: There were 22 females and 8 male patients in this study. Mean age was 42.4 years. Mean operative time in laparoscopic surgery was 80.25± 2.43 minutes versus 60±3.44 minutes. Mean hospital stay in laparoscopic was 3.5 days versus 5.5 days in open hernia repair. Conclusion: Laparoscopic meshplasty is better than open repair in terms of early recovery, less pain, minimal scar, early return to work.

Non-absorbable Barbed Sutures for Primary Fascial Closure in Laparoscopic Ventral Hernia Repair

Purpose

The aim of this study is to describe the safety and effectiveness of laparoscopic ventral hernia repair with intraperitoneal fascial closure using a barbed suture prior to mesh placement.

Materials and methods

Patients who underwent laparoscopic ventral hernia repair were included in this retrospective review. Patients were divided into two groups. In the first group, primary fascial closure was performed with a 2-polypropylene non-absorbable unidirectional barbed suture followed by fixation of the intraperitoneal mesh. In the second group, the mesh was fixed intraperitoneally using tacks without closing the fascial defect.

Results

A total of 148 patients who underwent laparoscopic primary ventral hernia repair were included. A total of 72 (48.6%) patients were included in the barbed suture with mesh group and 76 (51.4%) patients in the mesh-only group. The mean fascial defect size was 25 cm² in the first group and 64 cm² in the second group. The median suturing time for fascial closure was 15 minutes. The average surgery time was 98 minutes in the first group and 96 minutes in the second group. The mean follow-up period was 80 days for Group 1 and 135 days for Group 2. No hernia recurrence or mortality occurred in this study.

Conclusion

The barbed suture closure technique is a fast, safe, and effective technique for fascial closure during laparoscopic ventral hernia repair in combination with mesh placement. Further evidence to support these findings and longer follow-up periods are warranted to evaluate long-term outcomes.

Association between surgical hernia repair techniques and the incidence of seroma: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Ventral hernia repair (VHR) includes the surgical reconstruction of the abdominal wall (AW) using different surgical techniques. Although such procedures are usually devoid of complications, the formation of seroma may frequently occur. We performed a systematic review to assess the evidence from randomized controlled trials (RCTs) comparing VHR techniques and their impact on seroma formation.

METHODS

We included RCTs having seroma formation as primary endpoint. We included patients of both sexes (age > 18). For data synthesis we applied a random-effects model and calculated risk ratios (RR) with 95% confidence intervals (CI) using the Mantel-Haenszel method. Risk of bias (ROB) and publication bias were evaluated following Cochrane recommendations.

RESULTS

After database search and article screening, 21 records were included in this review. Ten RCTs compared onlay vs. sublay mesh placement techniques. Pooled analysis showed a significantly higher risk ratio for seroma in the onlay cohort (RR = 2.61, 95% CI 1.86-3.66, I² = 0, GRADE quality of evidence, moderate). Five RCTs compared laparoscopic intraperitoneal onlay mesh repair vs. open mesh placement. Pooled analysis showed that seroma formation did not differ significantly between groups (RR = 1.91, 95% CI 0.69-5.28, I² = 66%, GRADE quality of evidence, poor). High ROB was found in all studies and significant publication bias was detected in both meta-analyses.

CONCLUSION

Compared to sublay ventral hernia repair, the onlay procedure is associated with a significantly higher risk of seroma. No significant differences were observed when laparoscopic VHR was compared with the open surgical procedure. Due to the diversity of surgical techniques reported in included RCTs, it is currently not possible to draw conclusive clinical recommendations. Future studies should be standardized to provide detailed data allowing thorough evaluation of the impact of the evidence on clinical practice.

Recommendations for intraoperative mesh brachytherapy: Report of AAPM Task Group No. 222

Mesh brachytherapy is a special type of a permanent brachytherapy implant: it uses low-energy radioactive seeds in an absorbable mesh that is sutured onto the tumor bed immediately after a surgical resection. This treatment offers low additional risk to the patient as the implant procedure is carried out as part of the tumor resection surgery. Mesh brachytherapy utilizes identification of the tumor bed through direct visual evaluation during surgery or medical imaging following surgery through radiographic imaging of radio-opaque markers within the sources located on the tumor bed. Thus, mesh brachytherapy is customizable for individual patients. Mesh brachytherapy is an intraoperative procedure involving mesh implantation and potentially real-time treatment planning while the patient is under general anesthesia. The procedure is multidisciplinary and requires the complex coordination of multiple medical specialties. The preimplant dosimetry calculation can be performed days beforehand or expediently in the operating room with the use of lookup tables. In this report, the guidelines of American Association of Physicists in Medicine (AAPM) are presented on the physics aspects of mesh brachytherapy. It describes the selection of radioactive sources, design and preparation of the mesh, preimplant treatment planning using a Task Group (TG) 43-based lookup table, and postimplant dosimetric evaluation using the TG-43 formalism or advanced algorithms. It introduces quality metrics for the mesh implant and presents an example of a risk analysis based on the AAPM TG-100 report. Recommendations include that the preimplant treatment plan be based upon the TG-43 dose calculation formalism with the point source approximation, and the postimplant dosimetric evaluation be performed by using either the TG-43 approach, or preferably the newer model-based algorithms (viz., TG-186 report) if available to account for effects of material heterogeneities. To comply with the written directive and regulations governing the medical use of radionuclides, this report recommends that the prescription and written directive be based upon the implanted source strength, not target-volume dose coverage. The dose delivered by mesh implants can vary and depends upon multiple factors, such as postsurgery recovery and distortions in the implant shape over time. For the sake of consistency necessary for outcome analysis, prescriptions based on the lookup table (with selection of the intended dose, depth, and treatment area) are recommended, but the use of more advanced techniques that can account for real situations, such as material heterogeneities, implant geometric perturbations, and changes in source orientations, is encouraged in the dosimetric evaluation. The clinical workflow, logistics, and precautions are also presented.

SiPM-based gamma detector with a central GRIN lens for a visible/NIRF/gamma multi-modal laparoscope

Intraoperative imaging has been studied using conventional devices such as near infrared (NIR) optical probes and gamma probes. However, these devices have limited depth penetration and spatial resolution. In a previous study, we realized a multi-modal endoscopic system. However, charge-coupled device (CCD)-based gamma imaging required long acquisition times and lacked gamma energy information. A silicon photomultiplier (SiPM)-based gamma detector is implemented in a multi-modal laparoscope herein. A gradient index (GRIN) lens and CCD are used to transfer and readout visible and NIR photons. The feasibility of in-vivo sentinel lymph node (SLN) mapping was successfully performed with the proposed system.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03283982.

Minimally invasive repair for lateral ventral hernia: tailored approach from a hernia centre at a tertiary care institution

INTRODUCTION

Lateral ventral hernia (LVH) is rare and can be primary or secondary. Surgical treatment of this rare hernia type is challenging due the anatomic location and technical challenges in placement and secure anchoring of mesh.

METHOD

Patient demographic data, intra-operative data and post-operative outcomes on all LVH repairs performed with endo-laparoscopic and robotic approach between 2016 to 2018 were reviewed and analysed.

RESULTS

22 LVH were repaired in 21 patients. 9 had primary hernia and 13 had secondary hernia. All patients underwent minimally invasive surgery (MIS) for hernia repair with no conversion to open surgery. Fascial defect closure and placement of mesh were performed in all cases. Different approaches were utilized: 9 hernia repaired with laparoscopic intra-peritoneal on-lay mesh technique with defect closure (IPOM +), 4 had laparoscopic trans-abdominal pre-peritoneal repair (TAPP), another 4 had extended totally extra-peritoneal repair (eTEP), 3 had robotic TAPP (rTAPP) and 2 repaired with trans-abdominal partial extra-peritoneal (TAPE) approach. 4 (19%) of the patients developed post-operative seroma which were managed conservatively. No other significant complication was noted, and no chronic pain or recurrence reported within a minimum follow-up of 12 months.

CONCLUSION

This case series gives a broad outline of possible MIS options available for LVH repair and recommendations for a tailored approach. The surgical technique needs to be individualized according to the size and anatomic location of the defect, other intra-operative findings and patient characteristics.

Characterization and validation of multimodal annihilation-gamma/near-infrared/visible laparoscopic system

Minimally invasive robotic surgery using fluorescence-guided images with a video laparoscope has been widely used because of its advantages of small incision, fast recovery time, and efficiency. However, the penetration depth limitation of fluorescence is a disadvantage caused by the absorption and scattering in tissues and blood cells. If this limitation can be overcome by additional imaging modalities, the surgical procedure can be quite efficient and precise. High-energy annihilation-gamma photons have a stronger penetration capability than visible and fluorescence photons. To characterize and validate a multimodal annihilation-gamma/near-infrared (NIR)/visible laparoscopic imaging system, an internal detector composed of an annihilation-gamma detector and an optical system was assembled inside a surgical stainless pipe with an outer diameter of 15.8 mm and an external detector with a dimension of 100  ×  100  mm2 placed at the opposite side of the internal detector. Integrated images of 511-keV gamma rays, NIR fluorescence, and visible light were obtained simultaneously. The 511-keV gamma image could be clearly seen with the acquisition of 5 s, while NIR and visible images could be presented in real time. This multimodal system has the potential for improving the surgery time and the quality of patient care.

Laparoscopic Ventral Hernia Repair in South Auckland, New Zealand-A Retrospective Review

BACKGROUND

Ethnic disparities in surgical care and outcomes have been previously reported in studies for other surgical procedures. In addition, it has been reported that ethnic differences in postoperative analgesia exist. We aimed to determine ethnic disparities in postoperative outcomes, total opioid analgesia use, and complication rates of all patients who underwent a laparoscopic ventral hernia repair (LVHR) at our institution over a 3-y period.

METHODS

A retrospective review of all patients who underwent an LVHR at Counties Manukau Health from January 1, 2013, to December 31, 2015, was performed in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement.

RESULTS

A total of 267 ventral hernias were repaired in 254 patients at Counties Manukau Health over the study period, of which most were primary umbilical ventral hernias. The majority of patients in our cohort were New Zealand European and male. Major complications, as per the Clavien-Dindo classification grade 3 and above, were observed in six patients with no deaths (2.4%). There were no statistically significant ethnic disparities in length of stay, receipt of opioid analgesia, and rates of complication observed after linear regression modeling after adjustment for confounding factors.

CONCLUSIONS

Our study showed that the majority of patients who had a ventral hernia repaired at our institution were mostly New Zealand European and male. Although significant ethnic disparities in patient characteristics were observed, these were not associated with ethnic disparities in postoperative outcomes after an LVHR.

Emergency laparoscopic and open repair of incarcerated ventral hernias: a multi-institutional comparative analysis with coarsened exact matching

BACKGROUND

The safety of emergent laparoscopic repair of incarcerated ventral hernias is not well established. The objective of this study was to determine if emergent laparoscopic repair of incarcerated ventral hernias is comparable to open repair with respect to short-term clinical outcomes.

METHODS

Patients undergoing emergency repair of an incarcerated ventral hernia with associated obstruction and/or gangrene were identified using the ACS-NSQIP 2012-2016 dataset. One-to-one coarsened exact matching (CEM) was conducted between patients undergoing laparoscopic and open repair. Matched cohorts were compared with respect to morbidity, mortality, readmission, reoperation, missed enterotomies, and length of stay. Missed enterotomy was defined as any re-operative procedure within 30 days that required resection of large or small bowel segments, based on CPT codes. Multivariate analysis was conducted to determine adjusted predictors of morbidity.

RESULTS

A total of 1642 patients were identified after CEM. Laparoscopic compared to open repair was associated with a lower rate of 30-day wound-morbidity (OR 0.35, 95% CI 0.22-0.57, p < 0.001). Laparoscopic repair was not associated with lower 30-day non-wound morbidity (OR 0.73, 95% CI 0.51-1.06, p = 0.094). Laparoscopic repair was associated with shorter LOS (3.6 days vs. 4.3 days, p = 0.014). A higher rate of missed enterotomies was observed in the laparoscopic cohort (0.7% vs. 0.0%, p = 0.031). There were no group differences with respect to 30-day readmission, reoperation, or mortality.

CONCLUSIONS

Emergency laparoscopic repair of incarcerated ventral hernias is associated with lower rates of wound-morbidity and shorter hospital stays compared to open repair. However, laparoscopic repair is associated with a higher rate of missed enterotomies; a rate which is low and comparable to elective non-incarcerated ventral hernia repairs.

A decade of experience with laparoscopic ventral hernia repairs

BACKGROUND

Few studies have evaluated surgical outcomes in long-term follow-up for patients undergoing Laparoscopic Ventral Hernia Repair (LVHR).

METHODS

A retrospective review of long-term follow-up of LVHR patients (2002-2005) at a single institution.

RESULTS

Sixty-three patients (37 males; mean age = 63, mean BMI = 33, 41% for recurrence) underwent LVHR. Mean operative time was 164 min. Mean hospital stay was 3.7 days. Short- and long-term complications occurred in 19% and 44% of patients, respectively. Mean follow-up was 12.4 years. Recurrent hernias were noted in 15 patients. Seroma formation occurred in 14 patients; small bowel obstruction occurred in 10 patients. Five patients developed mesh infection. Use of PTFE mesh, longer operative time, and a larger hernia defect were risk factors for mesh infection (p < 0.05).

CONCLUSIONS

Long-term outcomes for patients undergoing LVHR are fraught with complications (44%) and a considerable risk of hernia recurrence (23%).

Systematic review and meta-analysis of robotic versus open hepatectomy

BACKGROUND

To date, there are few studies comparing the outcomes of robotic hepatectomy (RH) versus open hepatectomy (OH). We report the first systematic review and meta-analysis comparing the outcomes of RH versus OH.

METHODS

A systemic review was performed of all comparative studies of RH versus OH that reported the perioperative outcome(s) of interest.

RESULTS

Seven retrospective cohort studies were included. There was no significant difference in patients' baseline characteristics. RH was associated with a longer operation time (mean difference (MD) 61.47 min; 95% confidence interval (CI) (7.03, 115.91); P = 0.03), shorter hospital stay (MD -2.57 days; 95% CI (-3.31, -1.82); P < 0.001), lower costs, less overall (risk ratio (RR) 0.63; 95% CI (0.46, 0.86); P = 0.004), minor (RR 0.64; 95% CI (0.43, 0.95); P = 0.03) and major (RR 0.45; 95% CI (0.22, 0.94); P = 0.03) post-operative complications compared to OH.

CONCLUSION

RH had superior perioperative outcomes and was not cost prohibitive compared to OH, but had longer operation times.

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

Abdominal wall reconstruction is a rapidly evolving area of surgical interest. Due to the increase in prevalence and size of ventral hernias and the high recurrence rates, the academic community has become motivated to find the best reconstruction techniques. Whilst interrogating the abdominal wall reconstruction literature, we discovered an inconsistency in hernia nomenclature that must be addressed. The terms used to describe the anatomical planes of mesh implantation ‘inlay’, ‘sublay’ and ‘underlay’ are misinterpreted throughout. We describe the misinterpretation of these terms and give evidence of where it exists in the literature. We give three critical arguments of why these misinterpretations hinder advances in abdominal wall reconstruction research. The correct definitions of the anatomical planes, and their respective terms, are described and illustrated. Clearly defined nomenclature is required as academic surgeons strive to improve abdominal wall reconstruction outcomes and lower complication rates.

The Treatment of Incisional Hernia

BACKGROUND

A meta-analysis of studies from multiple countries has shown that the incidence of incisional hernia varies from 4% to 10% depending on the type of operation. No epidemiological surveys have been conducted so far. The worst possible complication of an incisional hernia if it is not treated surgically is incarceration. In this article, we present the main surgical methods of treating this condition. We also evaluate the available randomized and controlled trials (RCTs) in which open and laparoscopic techniques were compared and analyze the patients' quality of life.

METHODS

We selectively searched PubMed for relevant literature using the search terms "incisional hernia" and "randomized controlled trial." 9 RCTs were included in the analysis. The endpoints of the meta-analysis were the number of reoperations, complications, and recurrences. The observed events were studied statistically by correlation of two unpaired groups with a fixed-effects model and with a random-effects model. We analyzed the quality of life in our.

RESULTS

Open surgery and laparoscopic surgery for the repair of incisional hernias have similar rates of reoperation (odds ratio [OR] 0.419 favoring laparoscopy, 95% confidence interval [0.159; 1.100]; p = 0.077). The rates of surgical complications are also similar (OR 0.706; 95% CI [0.278; 1.783]; p = 0.461), although the data are highly heterogeneous, and the recurrence rates are comparable as well (OR 1.301; 95% CI [0,761; 2,225]; p = 0.336). In our own patient cohort in Würzburg, the quality of life was better in multiple categories one year after surgery.

CONCLUSION

The operative treatment of incisional hernia markedly improves patients' quality of life. The currently available evidence regarding the complication rates of open and laparoscopic surgical repair is highly heterogeneous, and further RCTs on this subject would therefore be desirable. Moreover, new study models are needed so that well-founded individualized treatment algorithms can be developed.

A systematic methodological review of reported perioperative variables, postoperative outcomes and hernia recurrence from randomised controlled trials of elective ventral hernia repair: clear definitions and standardised datasets are needed

BACKGROUND

This systematic review assesses the perioperative variables and post-operative outcomes reported by randomised controlled trials (RCTs) of VH repair. This review focuses particularly on definitions of hernia recurrence and techniques used for detection.

OBJECTIVE

Our aim is to identify and quantify the inconsistencies in perioperative variable and postoperative outcome reporting, so as to justify future development of clear definitions of hernia recurrence and a standardised dataset of such variables.

METHODS

The PubMed database was searched for elective VH repair RCTs reported January 1995 to March 2016 inclusive. Three independent reviewers performed article screening, and two reviewers independently extracted data. Hernia recurrence, recurrence rate, timing and definitions of recurrence, and techniques used to detect recurrence were extracted. We also assessed reported post-operative complications, standardised operative outcomes, patient reported outcomes, pre-operative CT scan hernia dimensions, intra-operative variables, patient co-morbidity, and hernia morphology.

RESULTS

31 RCTs (3367 patients) were identified. Only 6 (19.3%) defined hernia recurrence and methods to detect recurrence were inconsistent. Sixty-four different clinical outcomes were reported across the RCTs, with wound infection (30 trials, 96.7%), hernia recurrence (30, 96.7%), seroma (29, 93.5%), length of hospital stay (22, 71%) and haematoma (21, 67.7%) reported most frequently. Fourteen (45%), 11 (35%) and 0 trials reported CT measurements of hernia defect area, width and loss of domain, respectively. No trial graded hernias using generally accepted scales.

CONCLUSION

VH RCTs report peri- and post-operative variables inconsistently, and with poor definitions. A standardised minimum dataset, including definitions of recurrence, is required.

Past, Present and Future of Surgical Meshes: A Review

Surgical meshes, in particular those used to repair hernias, have been in use since 1891. Since then, research in the area has expanded, given the vast number of post-surgery complications such as infection, fibrosis, adhesions, mesh rejection, and hernia recurrence. Researchers have focused on the analysis and implementation of a wide range of materials: meshes with different fiber size and porosity, a variety of manufacturing methods, and certainly a variety of surgical and implantation procedures. Currently, surface modification methods and development of nanofiber based systems are actively being explored as areas of opportunity to retain material strength and increase biocompatibility of available meshes. This review summarizes the history of surgical meshes and presents an overview of commercial surgical meshes, their properties, manufacturing methods, and observed biological response, as well as the requirements for an ideal surgical mesh and potential manufacturing methods.

Outcomes after laparoscopic ventral hernia repair: does the number of previous recurrences matter? A prospective study

BACKGROUND

It is not yet clearly known whether laparoscopic ventral hernia repair (LVHR) is superior to the open approach in recurrent hernias. The aim of this study is to determine the safety and efficacy of laparoscopic technique for ventral hernias and investigate whether these outcomes are affected by the number of previous failed repairs.

METHODS

Data from 124 consecutive patients who underwent LVHR using a standardized technique between September 2007 and June 2014 were collected prospectively. In all repairs, a composite prosthesis was tailored to overlap the defect by at least 5 cm and fixed with a double crown of spiral tacks. Clinical follow-up visits were performed at 1 week, 1, 6, and 12 months, and yearly thereafter. Patients were classified in 3 groups (0, 1, and ≥ 2) according to the number of previous hernia repairs for further statistical analysis.

RESULTS

Long-term surveillance was available in 116 (93%) patients. Of these, 96 (82.8%) were recurrent hernias. There were 2 (1.7%) conversions, both in recurrent cases, and in 3 (2.6%) patients a hybrid access was used. Mean operating time was 55 min. There was an overall postoperative complication rate of 16%, with no mortality. During a mean follow-up of 30 (range 20-90) months, 3 (2.6%) recurrences were diagnosed 6, 8, and 9 months after surgery, respectively. A univariate analysis related to demographic, clinical, and perioperative variables did not find any significant relationship between the number of previous recurrences and operating time, conversion rate, hospital length of stay, overall morbidity, or recurrence.

CONCLUSIONS

This study suggests that laparoscopic approach in recurrent incisional hernias is a safe and feasible alternative to open techniques. Furthermore, our experience supports the idea that LVHR may be the best option for recurrent cases in properly selected patients, independently of the number of previous recurrences.

Robot-Assisted Transabdominal Preperitoneal Ventral Hernia Repair

BACKGROUND AND OBJECTIVES

We believe that complications due to the mesh used in ventral hernia repairs can be reduced by using the natural barrier afforded by the peritoneum. This can be challenging to do laparoscopically, however we felt that the robot-assisted laparoscopic approach reduces the difficulty in placing the mesh in the preperitoneal space, and we want to share our early experiences with this approach. We describe the surgical technique used in robot-assisted laparoscopic transabdominal preperitoneal (TAPP) ventral hernia repair with mesh. In addition, we evaluate its feasibility and present preliminary perioperative results.

METHODS

We performed robot-assisted laparoscopic TAPP ventral hernia repairs in 3 patients in the spring of 2015. Demographic information and defect size were measured. Conversion from a laparoscopic to an open procedure was the primary outcome variable.

RESULTS

There were 3 cases of robot-assisted TAPP ventral hernia repair with mesh. The mean age of the patients was 49 years, the mean body mass index was 32.6 kg/m(2), and the mean operative time was 163.7 minutes. The mean defect size was 1219.0 mm(2). There were no conversions to open during this early learning phase. All patients were discharged home within the 24-hour postoperative period. No complications were noted during a mean follow-up of 3 months.

CONCLUSIONS

We present our early experience with robot-assisted TAPP ventral hernia repair. We note that because of improved ergonomics and wristed instrumentation, the robotic platform enabled creation of peritoneal flaps and complete coverage of mesh with peritoneum after primary closure of the defect. The robotic approach is feasible and may provide a better environment for mesh integration and protection. Further investigations with long-term follow-up are needed to verify that this technique is effective in reducing mesh-related intra-abdominal complications.

Single incision laparoscopic primary and incisional ventral hernia repair as the standard of care in the ambulatory setting; Does less equal better outcomes; Case series and literature review

INTRODUCTION

The consensus about whether the single port approach is advantageous remains controversial. As the ambulatory service becomes the standard of care, techniques are in evolution to augment the patient experience in this setting. This forms the basis for evaluating SILS (Single Incision Laparoscopic Surgery) prosthetic ventral hernia repair in the ambulatory setting. We report a SILS technique of ventral hernia repair using the Stryker Ideal-eyes articulating laparoscope and standard laparoscopic instruments in the day-case setting.

PRESENTATION OF CASES

We report three cases of ventral hernias (one primary and two incisional). All were completed using single port techniques. They were done in the ambulatory setting and require no admission. Single incision laparoscopic repair of primary and incisional ventral hernias was completed successfully in all cases without conversion to standard laparoscopy. Median (range) operative time was 66min (39-95min). No intra- or postoperative complications were recorded. No episodes of prolonged postoperative pain were reported. We examine the literature and subsequently discuss the feasibility of ambulatory single port ventral hernia repair.

CONCLUSION

SILS prosthetic repair of primary and incisional ventral hernia is easily feasible. In our series, SILS ventral hernia repair appears to be safe and effective. It may decrease parietal trauma augmenting its use in the ambulatory setting. Technology will continue to improve the wide applicability of this technique. Larger randomized trial studies are required to determine the rates of port-site incisional hernia compared with multiport laparoscopy.

Patient-Reported Outcomes after Laparoscopic Ventral Hernia Repair

Approximately 350,000 ventral hernia repairs are performed in the United States each year. Patients expect fast recovery after laparoscopic ventral hernia repair (LVHR) and undisturbed postoperative quality of life (QOL). We examined the utility of a brief, validated 10-point Linear Analog Self-Assessment coupled with the Visual Analog Scale pain scale to discern risk factors for decreased postoperative QOL. Between January 2011 and May 2013, we prospectively assessed patient-reported outcomes for patients who underwent LVHR. Visual Analog Scale pain scale and Linear Analog Self-Assessment items were recorded preoperatively and postoperatively at four hours, one day, and seven days. Eighteen patients were included, 11 were female (61%) and 8 > 60 years old (44%). Patient-reported fatigue increased clinically and statistically from baseline over time ( P = 0.007) as did pain ( P < 0.001). There was a statistically significant difference in QOL scores over time by gender with women reporting worse scores than men ( P = 0.001). In conclusion, our study detected significant changes from baseline in both fatigue and pain over the seven days after LVHR. Age is associated with postoperative differences in physical well-being. Gender is associated with differences in postoperative course in QOL and physical well-being.

Magnetic Surgical Instruments for Robotic Abdominal Surgery

This review looks at the implementation of magnetic-based approaches in surgical instruments for abdominal surgeries. As abdominal surgical techniques advance toward minimizing surgical trauma, surgical instruments are enhanced to support such an objective through the exploration of magnetic-based systems. With this design approach, surgical devices are given the capabilities to be fully inserted intraabdominally to achieve access to all abdominal quadrants, without the conventional rigid link connection with the external unit. The variety of intraabdominal surgical devices are anchored, guided, and actuated by external units, with power and torque transmitted across the abdominal wall through magnetic linkage. This addresses many constraints encountered by conventional laparoscopic tools, such as loss of triangulation, fulcrum effect, and loss/lack of dexterity for surgical tasks. Design requirements of clinical considerations to aid the successful development of magnetic surgical instruments, are also discussed.

The usefulness of laparoscopic hernia repair in the management of incisional hernia following liver transplantation

INTRODUCTION

The reported incidence of incisional hernia following orthotopic liver transplantation (OLT) varies from 4% to 23%. Postoperative wound complications are less frequent after laparoscopic repair while maintaining low recurrence rates. We present our experience in managing this complication.

MATERIALS AND METHODS

Retrospectively, collected data of all patients who underwent liver transplant and developed incisional hernias were analyzed. Patients' demographic data, anthropometric data, transplantation-related data, and repair-related operative and postoperative data were collected. Risk factors for post-transplant incisional hernia were appraised in our patients. Patients were divided into two groups: Group A included patients who had their incisional hernia repaired through the laparoscopic approach, and Group B included patients who had their incisional hernia repaired through open conventional approach.

RESULTS

A total of 488 liver transplantations were performed at our institution between May 2001 and end of December 2012. Thirty-three patients developed incisional hernias after primary direct closure of the abdominal wall with an overall incidence of 6.9%. Hernia repair was done in 25 patients. Follow-up ranged from 6.4 to 106.1 months with a mean of 48.3 ± 28.3 months. All patients were living at the end of the follow up except four patients (16%). Group A included 13 patients, and Group B included 12 patients. The size of defects and operative time did not differ significantly between both the groups. On the other hand, hospital stay was significantly shorter in laparoscopic group. Complication rate following laparoscopic repair was insignificantly different for open repair.

CONCLUSION

In experienced hands, laparoscopic incisional hernia repair in post-liver transplant setting proved to be a safe and feasible alternative to open approach and showed superior outcome expressed in shorter hospital stay, with low recurrence and complication rate.

Pneumoperitoneum simulation based on mass-spring-damper models for laparoscopic surgical planning

Laparoscopic surgery, which is one minimally invasive surgical technique that is now widely performed, is done by making a working space (pneumoperitoneum) by infusing carbon dioxide ([Formula: see text]) gas into the abdominal cavity. A virtual pneumoperitoneum method that simulates the abdominal wall and viscera motion by the pneumoperitoneum based on mass-spring-damper models (MSDMs) with mechanical properties is proposed. Our proposed method simulates the pneumoperitoneum based on MSDMs and Newton's equations of motion. The parameters of MSDMs are determined by the anatomical knowledge of the mechanical properties of human tissues. Virtual [Formula: see text] gas pressure is applied to the boundary surface of the abdominal cavity. The abdominal shapes after creation of the pneumoperitoneum are computed by solving the equations of motion. The mean position errors of our proposed method using 10 mmHg virtual gas pressure were [Formula: see text], and the position error of the previous method proposed by Kitasaka et al. was 35.6 mm. The differences in the errors were statistically significant ([Formula: see text], Student's [Formula: see text]-test). The position error of the proposed method was reduced from [Formula: see text] to [Formula: see text] using 30 mmHg virtual gas pressure. The proposed method simulated abdominal wall motion by infused gas pressure and generated deformed volumetric images from a preoperative volumetric image. Our method predicted abdominal wall deformation by just giving the [Formula: see text] gas pressure and the tissue properties. Measurement of the visceral displacement will be required to validate the visceral motion.

Proposal of ecographic classification for seroma after laparoscopic ventral hernia repair

INTRODUCTION

Seroma is one of the most common complications after laparoscopic ventral hernia repair (LVHR), even if the incidence brought in literature is varying because definition and criterions of evaluation employed in the different studies are not always the same. This study proposes a classification for seroma after LVHR based on ultrasound findings, useful for an assessment of this complication.

MATERIALS AND METHODS

On 93 patients submitted to LVHR an ultrasound of the abdominal wall after 3, 7, 15, 21 and 28 days and subsequently at a distance of 3 and 6 months was performed postoperatively. At each control site, sonomorphology characteristics and size of seroma (if present) were noted.

RESULTS

At the end of the study using ultrasound findings obtained, a classification scheme for seroma articulated into three groups based on the parameters detected (site, sonomorphology character and volume) was developed, each of which is subdivided into five different classes to which a precise score is assigned. From the sum of the scores assigned, a value (between 3 and 15) that represents a prognostic index (PI) is obtained. A low PI is typical of small asymptomatic seroma that resolves spontaneously in a short time and without the need for invasive therapies; a high PI is typical of more or less symptomatic voluminous seroma that tends to persist for long periods and which often requires an interventional therapeutic approach.

CONCLUSIONS

This proposed classification helps to perform a precise nosological assessment of seroma after LVHR, allowing the surgeon to predict the clinical and temporal evolution of this complication and to plan appropriate therapy from time to time. Furthermore this classification can represent a tool to assess the uniqueness of seroma formation in relation to surgical technique used, to the type of material employed and to the method of mesh fixing.

Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies

INTRODUCTION

Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either simple diverticulitis (SD) or complicated diverticulitis (CD).

PURPOSE

To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis.

METHODS

Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively.

RESULTS

Of the 576 patients in the CRSD, 139 (24.1%) had CD. The overall conversion rate was 12.8% (n = 74). The average BMI was 29.8 kg/m(2). The conversion rate for CD was 12.2%. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days, p = 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days, p = 0.08). The overall anastomotic leak rate was 2.1% (n = 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0% (n = 38), whereas those with CD had a postoperative morbidity rate of 19.6% (n = 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4%, n = 5, p = 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95% CI 1.11-3.46, p = 0.02) was found to be an independent risk factor for the development of postoperative complications.

CONCLUSIONS

Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.

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

BACKGROUND

Laparoscopic incisional and ventral hernia repair (LIVHR) is an alternative approach to conventional open incisional and ventral hernia repair (OIVHR). A consensus on outcomes of LIVHR when compared with OIVHR has not been reached.

METHODS

As the basis for the present study, we performed a systematic review and meta-analysis of all randomized controlled trials comparing LIVHR and OIVHR.

RESULTS

Eleven studies involving 1,003 patients were enrolled. The incidences of wound infection were significantly lower in the laparoscopic group than that in the open group (laparoscopic group 2.8 %, open group 16.2 %; RR = 0.19, 95 % CI 0.11-0.32; P < 0.00001). The rates of wound drainage were significantly lower in the laparoscopic group than that in the open group (laparoscopic group 2.6 %, open group 67.0 %; RR = 0.06, 95 % CI 0.03-0.09; P < 0.00001). However, the rates of bowel injury were significantly higher in the laparoscopic group than in the open group (laparoscopic group 4.3 %, open group 0.81 %; RR = 3.68, 95 % CI 1.56-8.67; P = 0.003). There were no significant differences between the two groups in the incidences of hernia recurrence, postoperative seroma, hematoma, bowel obstruction, bleeding, and reoperation. Descriptive analyses showed a shorter length of hospital stay in the laparoscopic group.

CONCLUSIONS

Laparoscopic incisional and ventral hernia repair is a feasible and effective alternative to the open technique. It is associated with lower incidences of wound infection and shorter length of hospital stay. However, caution is required because it is associated with an increased risk of bowel injury compared with the open technique. Given the relatively short follow-up duration of trials included in the systematic review, trials with long-term follow-up are needed to compare the durability of laparoscopic and open 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.

Laparoscopic-Assisted Transversus Abdominis Plane Block for Postoperative Pain Control in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) is associated with considerable postoperative pain. Transversus abdominis plane (TAP) blocks have proven effective in controlling postoperative pain in a variety of laparoscopic abdominal operations. To date, no studies have focused on TAP blocks in LVHR. Our goal was to assess whether TAP blocks reduce opioid requirements and pain scores after LVHR.

STUDY DESIGN

Patients undergoing LVHR were randomly assigned to receive a TAP block or placebo injection. The primary end points were cumulative opioid use at 1, 3, 6, 12, 18, and 24 hours postoperatively and pain scores recorded at 1 and 24 hours postoperatively.

RESULTS

Patients in the experimental TAP group (n = 52) and control group (n = 48) were comparable with respect to patient demographics and clinical characteristics. In the postanesthesia care unit, the TAP group had significantly lower pain scores than the control group (p < 0.05). Patients in the TAP group used less opioids than the control group at each time point assessed after 6 hours postoperatively (p < 0.05). There was no significant difference in pain scores at 24 hours postoperatively (p > 0.05).

CONCLUSIONS

Transversus abdominis plane blocks given during LVHR significantly decrease both short-term postoperative opioid use and pain experienced by patients.

Meta-analysis and systematic review of laparoscopic versus open mesh repair for elective incisional hernia

CONTEXT

The utility of laparoscopic repair in the treatment of incisional hernia repair is still contentious.

OBJECTIVES

The aim was to conduct a meta-analysis of RCTs investigating the surgical and postsurgical outcomes of elective incisional hernia by open versus laparoscopic method.

DATA SOURCES

A search of PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1993 and September 2013 was performed using medical subject headings (MESH) "hernia," "incisional," "abdominal," "randomized/randomised controlled trial," "abdominal wall hernia," "laparoscopic repair," "open repair", "human" and "English".

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Prospective RCTs comparing surgical treatment of only incisional hernia (and not primary ventral hernias) using open and laparoscopic methods were selected.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data extraction and critical appraisal were carried out independently by two authors (AA and MAM) using predefined data fields. The outcome variables analyzed included (a) hernia diameter; (b) operative time; (c) length of hospital stay; (d) overall complication rate; (e) bowel complications; (f) reoperation; (g) wound infection; (h) wound hematoma or seroma; (i) time to oral intake; (j) back to work; (k) recurrence rate; and (l) postoperative neuralgia. These outcomes were unanimously decided to be important since they influence the practical and surgical approach towards hernia management within hospitals and institutions. The quality of RCTs was assessed using Jadad's scoring system. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity amongst the outcome variables of these trials was determined by the Cochran Q statistic and I (2) index. The meta-analysis was prepared in accordance with PRISMA guidelines.

RESULTS

Sufficient data were available for the analysis of twelve clinically relevant outcomes. Statistically significant reduction in bowel complications was noted with open surgery compared to the laparoscopic repair in five studies (OR 2.56, 95 % CI 1.15, 5.72, p = 0.02). Comparable effects were noted for other variables which include hernia diameter (SMD -0.27, 95 % CI -0.77, 0.23, p = 0.29), operative time (SMD -0.08, 95 % CI -4.46, 4.30, p = 0.97), overall complications (OR -1.07, 95 % CI -0.33, 3.42, p = 0.91), wound infection (OR 0.49, 95 % CI 0.09, 2.67, p = 0.41), wound hematoma or seroma (OR 1.54, 95 % CI 0.58, 4.09, p = 0.38), reoperation rate (OR -0.32, 95 % CI 0.07, 1.43, p = 0.14), time to oral intake (SMD -0.16, 95 % CI -1.97, 2.28, p = 0.89), length of hospital stay (SMD -0.83, 95 % CI -2.22, 0.56, p = 0.24), back to work (SMD -3.14, 95 % CI -8.92, 2.64, p = 0.29), recurrence rate (OR 1.41, 95 % CI 0.81, 2.46, p = 0.23), and postoperative neuralgia (OR 0.48, 95 % CI 0.16, 1.46, p = 0.20).

CONCLUSIONS

On the basis of our meta-analysis, we conclude that laparoscopic and open repair of incisional hernia is comparable. A larger randomized controlled multicenter trial with strict inclusion and exclusion criteria and standardized techniques for both repairs is required to demonstrate the superiority of one technique over the other.

Evaluation of absorbable mesh fixation devices at various deployment angles

BACKGROUND

Hernia repair failure may occur due to suboptimal mesh fixation by mechanical constructs before mesh integration. Construct design and acute penetration angle may alter mesh-tissue fixation strength. We compared acute fixation strengths of absorbable fixation devices at various deployment angles, directions of loading, and construct orientations.

METHODS

Porcine abdominal walls were sectioned. Constructs were deployed at 30°, 45°, 60°, and 90° angles to fix mesh to the tissue specimens. Lap-shear testing was performed in upward, downward, and lateral directions in relation to the abdominal wall cranial-caudal axis to evaluate fixation. Absorbatack™ (AT), SorbaFix™ (SF), and SecureStrap™ in vertical (SSV) and horizontal (SSH) orientations in relation to the abdominal wall cranial-caudal axis were tested. Ten tests were performed for each combination of device, angle, and loading direction. Failure types and strength data were recorded. ANOVA with Tukey-Kramer adjustments for multiple comparisons and χ (2) tests were performed as appropriate (p < 0.05 considered significant).

RESULTS

At 30°, SSH and SSV had greater fixation strengths (12.95, 12.98 N, respectively) than SF (5.70 N; p = 0.0057, p = 0.0053, respectively). At 45°, mean fixation strength of SSH was significantly greater than SF (18.14, 11.40 N; p = 0.0002). No differences in strength were identified at 60° or 90°. No differences in strength were noted between SSV and SSH with different directions of loading. No differences were noted between SS and AT at any angle. Immediate failure was associated with SF (p < 0.0001) and the 30° tacking angle (p < 0.01).

CONCLUSIONS

Mesh-tissue fixation was stronger at acute deployment angles with SS compared to SF constructs. The 30° angle and the SF device were associated with increased immediate failures. Varying construct and loading direction did not generate statistically significant differences in the fixation strength of absorbable fixation devices in this study.

Patient-centered outcomes following laparoscopic ventral hernia repair: a systematic review of the current literature

BACKGROUND

The purpose of this study was to systematically review patients who underwent laparoscopic ventral hernia repair (LVHR) and assess quality of life, pain, functionality, and patient satisfaction.

DATA SOURCES

MEDLINE, PubMed, and Cochrane database search identified 880 relevant articles. After the limits were applied, 14 articles were accepted for review. The analysis included health-related quality of life (HRQoL) measures including quality of life, pain, function, satisfaction, and mental and emotional well-being.

CONCLUSIONS

Fourteen studies were reviewed. Mean study size was 92.6 subjects (24 to 306) and mean defect size was 71.7 cm(2). LVHR improved the overall HRQoL in 6 of the 8 studies. Thirteen studies assessing pain demonstrated improved pain scores relative to preoperative levels and long-term follow up. LVHR was not associated with long-term pain. Functionality improved in 12 studies. Return to work ranged from 6 to 18 days postoperatively in 50% of studies and physical function scores improved in the remaining 50% of the studies. Patient satisfaction improved after LVHR in all studies assessing patient satisfaction. Fixation methods did not influence HRQoL. Laparoscopic repair was associated with improving mental and emotional well-being in 6 of the 7 studies.

LAPAROSCOPY VERSUS LAPAROTOMY IN THE REPAIR OF VENTRAL HERNIAS: systematic review and meta-analysis

Objective To compare the laparotomy and laparoscopy techniques for correction of ventral hernia when related to perioperative complications, length of hospitalization, surgical time, and recurrence of hernia. Methods This was a systematic review of randomized controlled trials, which included studies retrieved from four databases (MEDLINE, Embase, Cochrane and LILACS), using a combination of the terms (Hernia, Ventral) and (Laparoscopy) and (Laparotomy). Results Six randomized trials were included, totaling 566 patients, 283 in the Laparoscopy group and 283 in the Laparotomy group. Laparoscopy reduced the risk of infection of the surgical wound (NNT = 5) and seroma formation (NNT = 13) and less length hospitalization (P = 0.02) compared to laparotomy in the correction of ventral hernias. Furthermore, laparoscopy increased the incidence of enterotomy (NNH = 25) and post operative pain (NNH = 8) and longer surgical time (P = 0.0009) when compared with laparotomy. There was no difference related to abscess (P = 0.79), hematoma (P = 0.43) and recurrency of ventral hernias (P = 0.25). Conclusions In the correction of ventral hernias, the use of laparoscopic technique is effective to reduce infections of the surgical wound and seroma formation, as well as, decrease the length hospitalization.

Foreign body reaction associated with PET and PET/chitosan electrospun nanofibrous abdominal meshes

Electrospun materials have been widely explored for biomedical applications because of their advantageous characteristics, i.e., tridimensional nanofibrous structure with high surface-to-volume ratio, high porosity, and pore interconnectivity. Furthermore, considering the similarities between the nanofiber networks and the extracellular matrix (ECM), as well as the accepted role of changes in ECM for hernia repair, electrospun polymer fiber assemblies have emerged as potential materials for incisional hernia repair. In this work, we describe the application of electrospun non-absorbable mats based on poly(ethylene terephthalate) (PET) in the repair of abdominal defects, comparing the performance of these meshes with that of a commercial polypropylene mesh and a multifilament PET mesh. PET and PET/chitosan electrospun meshes revealed good performance during incisional hernia surgery, post-operative period, and no evidence of intestinal adhesion was found. The electrospun meshes were flexible with high suture retention, showing tensile strengths of 3 MPa and breaking strains of 8-33%. Nevertheless, a significant foreign body reaction (FBR) was observed in animals treated with the nanofibrous materials. Animals implanted with PET and PET/chitosan electrospun meshes (fiber diameter of 0.71 ± 0.28 µm and 3.01 ± 0.72 µm, respectively) showed, respectively, foreign body granuloma formation, averaging 4.2-fold and 7.4-fold greater than the control commercial mesh group (Marlex). Many foreign body giant cells (FBGC) involving nanofiber pieces were also found in the PET and PET/chitosan groups (11.9 and 19.3 times more FBGC than control, respectively). In contrast, no important FBR was observed for PET microfibers (fiber diameter = 18.9 ± 0.21 µm). Therefore, we suggest that the reduced dimension and the high surface-to-volume ratio of the electrospun fibers caused the FBR reaction, pointing out the need for further studies to elucidate the mechanisms underlying interactions between cells/tissues and nanofibrous materials in order to gain a better understanding of the implantation risks associated with nanostructured biomaterials.

Tratamento de hérnias da linha média do abdome com uso de grampeador endoscópico para fechamento da linha média

INTRODUÇÃO: A cirurgia minimamente invasiva modificou a maneira de analisar e dissecar os tecidos nos procedimentos cirúrgicos. No entanto, a vantagem deste método é limitada na parede abdominal, devido à falta de desenvolvimento de tecnologias e movimentos articulados para seu emprego nesta região, exigindo a necessidade de investimentos e de tempo para a solidificação. Esta abordagem para reparo operatório da parede abdominal é baseada nos princípios Rives-Stoppa. TÉCNICA: Com o paciente em decúbito dorsal, uma pequena incisão supra-púbica é feita e o espaço pré-peritoneal é alcançado e insuflado. Após os trocárteres serem colocados, o saco peritoneal é dissecado e a cavidade abdominal é atingida acima da linha arqueada. As bainhas posteriores do músculo reto do abdome são liberadas e um grampeador linear é colocado em ambos os lados e acionado, restituindo a linha média e criando um espaço retromuscular, onde a tela é colocada e fixada. CONCLUSÃO: O método é viável, fácil de realizar e reprodutível, economizando tempo e com resultado funcional satisfatório.

Suture versus tack fixation of mesh in laparoscopic umbilical hernia repair

BACKGROUND AND OBJECTIVES

Mesh fixation in laparoscopic umbilical hernia repair is poorly studied. We compared postoperative outcomes of laparoscopic umbilical hernia repair in suture versus tack mesh fixation.

METHODS

Patients who underwent laparoscopic umbilical hernia repair were separated by method of mesh fixation: sutures versus primarily tacks. Medical history and follow-up data were collected through medical records. The primary outcome of this study was the recurrence rates of hernias. Postoperative major and minor complications, such as surgical site infection, small-bowel obstruction, and seroma formation, were regarded as secondary outcomes. Additionally, a telephone interview was conducted to assess postoperative pain, recovery time, and overall patient satisfaction.

RESULTS

Eighty-six patients were identified: 33 in the suture group and 53 in the tacks group. The number of emergent cases was increased in the tacks group (6 vs 0; P = .022). Mean follow-up time was 2.7 years for both groups. Documented postoperative follow-up was obtained in 29 (90%) suture group and 31 (58%) tacks group patients. Hernia recurrence occurred in 3 and 2 patients in the sutures and tacks groups, respectively (P was not significant). No differences were found in secondary outcomes, including subjective outcomes from telephone interviews, between groups.

CONCLUSIONS

There are no differences in postoperative complication rates in suture versus tack mesh fixation in laparoscopic umbilical hernia repair.