Are mesh anchoring sutures necessary in ventral hernioplasty? Multicenter study

Treatment of rectus diastasis: should the midline always be reinforced with mesh? A systematic review

BACKGROUND

Two main trends are described for the treatment of diastasis recti: plication versus midline mesh reinforcement. Indications for these procedures have not been clearly described. This study reviewed the outcomes in the treatment of rectus diastasis with plication versus mesh by the assessment of durability, complications, and patient-reported outcomes.

MATERIALS AND METHODS

A systematic review of literature on the treatment of diastasis recti was performed searching through PubMed, Embase, Web of Science, and Cochrane databases. This resulted in 53 eligible articles and predefined inclusion criteria led to the selection of 24 articles. Primary outcomes included recurrence and perioperative complications and secondary outcomes were defined as patient satisfaction, chronic pain, and quality of life.

RESULTS

A total of 931 patients were surgically treated for rectus divarication (age range: 18 - 70 years). The most frequently noted comorbidity was obesity and 10.6 percent were smokers. Recurrence was reported in 5 percent of the patients. The most frequent complication was seroma (7 percent), followed by abdominal hypoesthesia (6 percent), and surgical site infection (2 percent). Chronic pain was reported in 4 percent of the patients. Satisfaction was assessed subjectively in the majority of patients and was generally rated as high. Follow-up period ranged from 3 weeks to 20 years.

CONCLUSIONS

Durability, safety, and high patient satisfaction support surgical correction of rectus diastasis and could not favor a treatment method. Inter-rectus distance could not be identified as the indicator for technique, which emphasizes that other factors might add to the entity of abdominal wall protrusion more than previously thought.

[Technical principles of incisional hernia surgery]

Many publications are available on the best surgical techniques and treatment of incisional hernias with reports of experiences and randomized clinical studies at the two extremes of the evidence scale. The ultimate proof of the best operative technique has, however, not yet been achieved. In practically no other field of surgery are the variability and the resulting potential aims of surgery so great. The aim of surgery is to provide patients with the optimal recommendation out of a catalogue of possibilities from a holistic perspective. This article describes the surgical techniques using meshes for strengthening (in combination with an anatomical reconstruction) and for replacement of the abdominal wall (with bridging of the defect).

Pain, quality of life and recovery after laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) is a well established procedure in the treatment of ventral hernias. It is our clinical experience that patients suffer intense postoperative pain, but this issue and other recovery parameters have not been studied in detail.

METHODS

Thirty-five patients with hernias >3 cm prospectively underwent LVHR using "double-crown" titanium tack mesh fixation. Pre- and postoperative pain was measured on a 0-100-mm visual analogue scale (VAS) and health-related quality of life was measured using the Short Form 36 questionnaire (SF-36). Several other recovery parameters were measured systematically in the 6 months follow-up period.

RESULTS

We observed no recurrences or severe complications in the follow-up period (n = 31 at day 30 and n = 28 after 6 months). The median in-hospital stay was 2 days (range 0-5). Patients reported significantly more pain during activity than at rest at all times (p < 0.05). The median VAS-pain score during activity vs. at rest at discharge was 60 and 31, respectively. The median VAS-pain score during activity on the day of operation (day 0) was 78; it returned to baseline values at day 30 (p = 0.148) and, after 6 months, it was below the preoperative score (p = 0.01). The scores for general well-being and fatigue returned to baseline values at days 3 and 30, respectively, and at 6 months, they had both significantly improved compared with preoperative values (p = 0.005). The SF-36 scores were significantly worse in three domains at day 30 (p < 0.005). After 6 months, the bodily pain score had increased significantly compared with preoperative values (p < 0.005) and all eight scales were comparable to the Danish reference population scores. Patients resumed normal daily activities after a median of 14 days (range 1-38). Smokers and patients with hard physical demands at work took a significantly longer amount of time to resume work compared with non-smokers (30 vs. 9 days, p < 0.005) and patients with light work demands (29 vs. 9 days, p < 0.05), respectively. VAS-pain scores were strongly correlated to general well-being (r = -0.8, p < 0.001), patient satisfaction (r = -0.67, p < 0.001) and quality of life (r = -0.63, p < 0.001). We found no significant correlation between the number of tacks used (median 59) and postoperative pain.

CONCLUSION

LVHR was associated with considerable postoperative pain and fatigue in the first postoperative month, prolonging the time of convalescence and significantly affecting patients' quality of life up to 6 months postoperatively. Mesh fixation with fibrin glue or other non-invasive/degradable products seems promising for reducing pain and it should be investigated in future randomised trials.