Isokinetic strength of the trunk flexor muscles after surgical repair for incisional hernia

The changes in abdominal wall muscles following incisional hernia wall reconstruction

PURPOSE

The objective of incisional hernia surgery is to achieve the restoration of abdominal wall anatomical and physiological functions. This study aims to investigate the impact of abdominal wall reconstruction on abdominal muscle alterations by measuring the preoperative and postoperative changes in abdominal wall muscles in patients undergoing incisional hernia repair.

METHODS

For patients undergoing open incisional hernia abdominal wall reconstruction, preoperative and postoperative abdominal CT scans were analyzed at a minimum of 3 months post-surgery. 3D Slicer software was utilized for measuring preoperative and postoperative changes in abdominal cavity volume, abdominal muscle volume, as well as muscle volume, cross-sectional area, and abdominal circumference at specific levels. The acquired data were subjected to statistical analysis using SPSS software.

RESULTS

A total of 40 patients meeting the inclusion criteria underwent open incisional hernia repair surgery. Some of these patients required component separation technique (CST) due to the larger size of the hernia sac. The abdominal muscles surrounding the hernia ring were defined as the "damaged group," while the remaining abdominal muscles were defined as the "undamaged group." Measurements revealed a significant increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the damaged group. Similarly, there was a corresponding increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the undamaged group.

CONCLUSIONS

After abdominal wall reconstruction in incisional hernia patients, not only is their anatomical structure restored, but the overall biomechanical integrity of the abdominal wall is also repaired. The damaged muscles are subjected to renewed loading, leading to the reversal of disuse atrophy and an increase in muscle volume.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

Reliability and criterion validity of handheld dynamometry for measuring trunk muscle strength in people with and without chronic non-specific low back pain

BACKGROUND

Evaluating trunk strength is an important aspect of the physical examination of people with low back pain (LBP). Thus, reliable, valid, and easily applied measurement tools are needed to quantify trunk muscle strength and monitor changes in response to interventions.

OBJECTIVES

To determine within-day and between-day test re-test reliability and criterion validity of a handheld dynamometer (HHD) to evaluate maximum isometric trunk strength in people with chronic LBP and asymptomatic individuals.

DESIGN

Reliability and criterion validity study.

METHODS

Twenty adult participants with chronic, non-specific LBP and 35 asymptomatic individuals participated. Isometric trunk flexion, extension, and rotation strength were evaluated with the HHD (Active force 2) and the within-day and between-day reliability were determined with intraclass correlation coefficients (ICC2,1) and the standard error of the measurements (SEM), minimal detectable change (MDC), and the limits of agreement (LOA) using Bland-Altman plots. Criterion validity was evaluated using Pearson correlation coefficients to compare HHD measurements to isokinetic dynamometry for both isometric trunk flexion and extension strength.

RESULTS

Good to excellent within-day and between-day reliability was observed for people with LBP and asymptomatic individuals with (ICC2,1) of 0.73-0.93 and 0.62-0.92 respectively. A moderate to strong correlation was found between measurements with the HHD and the isokinetic dynamometer with a correlation of r = 0.68-0.78 and r = 0.56-0.59 for people with LBP and asymptomatic participants respectively.

CONCLUSION

A HHD is a reliable, valid, and clinically applicable tool for the measurement of trunk strength in adults with and without chronic LBP.

The efficacy of isokinetic strength training versus core stability training on the trunk muscle strength and quality of life after surgical repair of incisional hernia in adolescents

Objectives

The study aimed to compare the impact of isokinetic strength training (IST) with core stability training (CST) in terms of trunk muscle strength and quality of life (QoL) after surgical repair of incisional hernia in adolescents.

Patients and methods

The prospective, randomized, comparative study was conducted at the College of Applied Medical Sciences, Department of Health and Rehabilitation Sciences between August 2019 and June 2020. Thirty patients (16 males, 14 females; mean age: 17.1±0.6 years; range, 12 to 18 years) who had undergone primary incisional hernia repair surgery were included in the study. The patients were randomly divided into two groups: the IST group of 15 patients who underwent the isokinetic exercise program for trunk muscles and the CST group of 15 patients who practiced the core exercise program. Each group exercised three times per week for six weeks. All patients were assessed pre-and post-treatment by an isokinetic dynamometer for trunk flexors and extensors at 60 and 90°/s angular velocities and the European Registry for Abdominal Wall Hernias (EuraHS)-QoL questionnaire.

Results

The trunk flexor and extensor Peak torque/body weight ratio at 60 and 90o/s angular velocities and QoL were significantly improved in both IST and CST groups (p<0.05). The post-treatment values of both groups revealed marked but not statistically significant differences in all measured variables (p>0.05).

Conclusion

Both IST and CST are effective training programs that can improve the strength of trunk flexors and extensors as well as QoL after surgical repair of incisional hernia in adolescents.

Physical activity recommendations pre and post abdominal wall reconstruction: a scoping review of the evidence

PURPOSE

There are no universally agreed guidelines regarding which types of physical activity are safe and/or recommended in the perioperative period for patients undergoing ventral hernia repair or abdominal wall reconstruction (AWR). This study is intended to identify and summarise the literature on this topic.

METHODS

Database searches of PubMed, CINAHL, Allied & Complementary medicine database, PEDro and Web of Science were performed followed by a snowballing search using two papers identified by the database search and four hand-selected papers of the authors' choosing. Inclusion-cohort studies, randomized controlled trials, prospective or retrospective. Studies concerning complex incisional hernia repairs and AWRs including a "prehabilitation" and/or "rehabilitation" program targeting the abdominal wall muscles in which the interventions were of a physical exercise nature. RoB2 and Robins-I were used to assess risk of bias. Prospero CRD42021236745. No external funding. Data from the included studies were extracted using a table based on the Cochrane Consumers and Communication Review Group's data extraction template.

RESULTS

The database search yielded 5423 records. After screening two titles were selected for inclusion in our study. The snowballing search identified 49 records. After screening one title was selected for inclusion in our study. Three total papers were included-two randomised studies and one cohort study (combined 423 patients). All three studies subjected their patients to varying types of physical activity preoperatively, one study also prescribed these activities postoperatively. The outcomes differed between the studies therefore meta-analysis was impossible-two studies measured hernia recurrence, one measured peak torque. All three studies showed improved outcomes in their study groups compared to controls however significant methodological flaws and confounding factors existed in all three studies. No adverse events were reported.

CONCLUSIONS

The literature supporting the advice given to patients regarding recommended physical activity levels in the perioperative period for AWR patients is sparse. Further research is urgently required on this subject.

Techniques for Closing the Abdominal Wall in Intestinal and Multivisceral Transplantation: A Systematic Review

Short bowel syndrome is the most common etiology of intestinal failure, resulting from either resections of different intestinal segments or a congenital condition. Due to the absence or considerable reduction of intestinal loops in the abdominal cavity, patients with short bowel syndrome present with atrophy and muscle retraction of the abdominal wall, which leads to loss of abdominal domain and elasticity. This complication is an aggravating factor of intestinal transplantation since it can prevent the primary closure of the abdominal wall. A vast array of surgical techniques to overcome the challenges of the complexity of the abdominal wall have been described in the literature. The aim of our study was to review the modalities of abdominal wall closure in intestinal/multivisceral transplantation. Our study consisted of a systematic review following the methodological instructions described in the PRISMA guidelines. Duplicate studies and studies that did not meet the criteria for the systematic review were excluded, especially those without relevance and an explicit relationship with the investigated theme. After this step, 63 articles were included in our study. The results obtained with these techniques have been encouraging, but a high incidence of wound complications in some reports has raised concerns. There is no consensus among transplantation centers regarding which technique would be ideal and with higher success rates and lower rates of complications.

Truncal function after abdominal wall reconstruction via transversus abdominis muscle release (TAR) for large incisional hernias: a prospective case-control study

BACKGROUND

Data about abdominal wall function in patients with incisional hernias (IH) are limited. Abdominal Wall Reconstruction (AWR) could be beneficial for the improvement of this function. The goal of the study was to evaluate if the abdominal wall function was restored after transversus abdominis muscle release (TAR).

METHODS

We performed a prospective case-control study of 59 patients with IH equal or larger than 10 cm in their width undergoing AWR via TAR with mesh reinforcement and complete linea alba restoration. With two simple physical tests-Trunk Raising (TR) and Double Leg Lowering (DLL), we clinically assessed, preoperatively, 1 month and 1 year postoperatively the functionality of the abdominal wall (flexion). Patients were compared with a control group (n = 57) with an intact abdominal wall undergoing visceral surgery through a midline laparotomy.

RESULTS

There were no differences between the groups in terms of sex and mean age. In the study group, TR demonstrated an increase from 1.93 preoperatively to 2.44 at 1 month and 4.27, respectively, at 1 year postoperatively (p < 0.001). DLL was improved from 2.067 to 4.37 at 1 year postoperatively (p = 0.016). In the control group, surgery resulted in a decrease of truncal flexion. At 1 year postoperatively, the abdominal wall function for study group patients was almost identical with that the functionality of the control group featuring an intact abdominal wall (TR 4.26 vs 4.33 p = 0.532; DLL 4.42 vs 4.21 p = 0.193).

CONCLUSION

AWR via TAR for large IH specifically improved long-term abdominal wall muscular function.

Changes in the abdominal wall after anterior, posterior, and combined component separation

KEY MESSAGE

Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essential for understanding the mechanisms of action of the various CS techniques, the changes observed on computed tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who have undergone CS. Purpose Component separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps most importantly, the anatomic and physiologic changes following CS techniques. Methods A systematic review of the literature was conducted using the PubMed database and other sources to identify articles describing abdominal wall changes after CS Results After excluding non-pertinent articles, 14 articles constituted the basis for this review.  Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the muscles' overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3) Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postoperative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and posterior CS are underway.

Mesh repair under the anterior lamina of the rectus sheath (MUAR) for abdominal incisional hernia

PURPOSE

Abdominal incisional hernia is a frequent complication of major abdominal operations. Our method of performing mesh repair under the anterior lamina of the rectus sheath (MUAR) involves placing mesh between the dorsal surface of the anterior rectus sheath and the rectus abdominis muscle. We evaluated the short-term and long-term outcomes of our MUAR method.

METHODS

The subjects of this retrospective study were 80 patients with abdominal incisional hernia, who underwent MUAR at our hospital between August, 2009 and September, 2018. We investigated the rate of recurrence and postoperative complications in these patients, who were followed-up postoperatively for at least 18 months. Patients who completed all visits were then followed-up further with questionnaires.

RESULTS

The recurrence rate after MUAR was 0%. Postoperative complications consisted of subcutaneous wound infections in two patients (2.5%), successfully treated with wound cleansing and antibiotics; and subcutaneous hematoma in three patients (3.8%), which was spontaneously absorbed in two patients, and removed in one. There were no other complications, such as seroma, intestinal obstruction, mesh infection and bulging, or prolonged postoperative pain.

CONCLUSION

Mesh repair under the anterior lamina of the rectus sheath is simple and safe with positive short-term and long-term outcomes, suggesting that it is a good option for incisional hernia repair.

Isokinetic trunk muscle performance in adolescents with different body mass indices

Objective

This study aims to evaluate the isokinetic performance for the peak torque and average power of the spinal flexor and extensor muscles in adolescents aged 12 to 18 years. The study also analyses the differences between the trunk muscle peak torque and average power with body mass index (BMI).

Method

The peak torque and average power of the trunk flexor and extensor muscles were measured in 180 adolescents (aged 12–18 years). The participants were classified into four groups according to BMI. The Biodex isokinetic dynamometer in concentric mode at speeds of 60° and 120°/sec was used for assessment.

Results

One-way multivariate analysis of variance MANOVA results demonstrated a significant difference in trunk muscle peak torque and average power with different BMI (F = 14.692, p = 0.0005). A Pearson's correlation analysis demonstrated a significantly negative correlation between weight and peak torque of trunk flexors and extensors (r = - 0.43, p = 0.0001; r = −0.31, p = 0.007, respectively). Finally, the results showed a negative correlation between weight and average power of trunk flexors and extensors (r = −0.54, p = 0.0001; r = −0.31, p = 0.007).

Conclusion

In this study, overweight and obese adolescents are found to be correlated with decreased trunk muscle torque and power. Thus, therapeutic interventions for overweight and obese adolescents, along with exercise training programmes, may help improve muscle performance including peak torque and power. Finally, these measures may enhance the quality of life of such adolescents.

Botulinum Toxin in the Surgical Treatment of Complex Abdominal Hernias: A Surgical Anatomy Approach, Current Evidence and Outcomes

BACKGROUND/AIM

Abdominal wall hernias represent a common problem in surgical practice. A significant proportion of them entails large defects, often difficult to primarily close without advanced techniques. Injection of botulinum toxin preoperatively at specific points targeting lateral abdominal wall musculature has been recently introduced as an adjunct in achieving primary fascia closure rates.

MATERIALS AND METHODS

A literature search was conducted investigating the role of botulinum toxin in abdominal wall reconstruction focusing on anatomic repair of hernia defects.

RESULTS

Injecting botulinum toxin preoperatively achieved chemical short-term paralysis of the lateral abdominal wall muscles, enabling a tension-free closure of the midline, which according to anatomic and clinical studies should be the goal of hernia repair. No significant complications from botulinum injections for complex hernias were reported.

CONCLUSION

Botulinum is a significant adjunct to complex abdominal wall reconstruction. Further studies are needed to standardize protocols and create more evidence.

Changes in the lateral abdominal wall following endoscopic subcutaneous anterior component separation

PURPOSE

Although changes in lateral abdominal wall musculature after posterior component separation with transversus abdominis release have been investigated, the effects of endoscopic subcutaneous anterior component separation (ES-ACS) on postoperative muscle anatomy have not been evaluated. The purpose of this study was to evaluate changes in the lateral abdominal muscles after ES-ACS.

METHODS

Computed tomography (CT) images of patients who underwent ES-ACS were retrospectively evaluated. Lateral abdominal wall thickness and external oblique displacement were measured at the level of fixed retroperitoneal structures. Measurements on the ES-ACS side were compared with those on the contralateral undivided side or with preoperative images in patients with bilateral procedures.

RESULTS

Fifteen patients met the criteria for study inclusion. Most patients (n = 13, 86.7%) underwent unilateral ES-ACS. The most commonly performed procedure was laparoscopic intraperitoneal onlay mesh-plus hernia repair (n = 12, 80.0%; the remaining patients underwent open repair). The Mean defect width was 8.4 cm (range 6-15 cm). There was no difference in the thickness of the lateral abdominal musculature between ES-ACS and undivided sides. There was a significant lateral displacement of the external oblique muscle from the lateral edge of the rectus abdominis on the ES-ACS side (mean distance 3.7 cm; p = 0.0006). No midline hernia recurrences, iatrogenic linea semilunaris hernias, or lateral eventrations were observed during a mean follow-up period of 2.6 years (range 0.5-7.4 years).

CONCLUSION

ES-ACS resulted in no atrophy of the lateral abdominal muscles in long-term CT follow-up. The procedure is a safe and effective adjunct to complex hernia repair in selected patients.

What is the best method to assess the abdominal wall? Restoring strength does not mean functional recovery

Background:

Restoring the contractile function to the abdominal wall is a major goal in hernia repair. However, the core understanding is required when choosing the method for outcome assessment.

Aim:

To assess the role of the anterolateral abdominal muscles on abdominal wall function in patients undergoing hernia repair by analysis of correlation between the surface electromyography activation signal of these muscles and torque produced during validated strength tests.

Methods:

Activation of the rectus abdominis, external oblique, and internal oblique/transverse abdominis muscles was evaluated by surface electromyography during two validated tests: Step: 1-A, isometric contraction in dorsal decubitus; 1-B, isometric contraction in lateral decubitus; 2-A, isokinetic Biodex testing; and 2-B, isometric Biodex testing.

Results:

Twenty healthy volunteers were evaluated. The linear correlation coefficient between root mean square/peak data obtained from surface electromyography signal analysis for each muscle and the peak torque variable was always <0.2 and statistically non-significant (p<0.05). The agonist/antagonist ratio showed a positive, significant, weak-to-moderate correlation in the external oblique (Peak, p=0.027; root mean square, 0.564). Surface electromyography results correlated positively among different abdominal contraction protocols, as well as with a daily physical activity questionnaire.

Conclusions:

There was no correlation between surface electromyography examination of the anterolateral abdominal wall muscles and torque measured by a validated instrument, except in a variable that does not directly represent torque generation.

Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

Many experts in abdominal wall reconstruction believe that the combination of simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is contraindicated. We performed ipsilateral endoscopic ACS and either endoscopic or open PCS-transversus abdominis release (TAR) in 5 fresh cadaver models. The full length of the semilunar line and the lateral abdominal wall remained well reinforced by 2 complete layers, comprising the internal oblique (IO) and TA muscles and their investing fasciae. Myofascial releases occurred 4 cm (median) apart. Additionally, we reviewed computed tomography images at 1 month and 1 year after PCS-TAR in 17 patients (30 PCS-TARs). Lateral displacement of the TA relative to the rectus abdominis (RA) was significant only at the superior mesenteric artery level, where it was <1 cm (median). Muscle mass changed minimally over time. Several studies showed that abdominal wall reconstruction after PCS-TAR results in compensatory muscular hypertrophy of the RA, external oblique (EO), and IO muscles and provides better quality of life and improved core physiology. These changes did not occur when the midline was not restored. Theoretically, endoscopic ACS-EO may be added to PCS-TAR to avoid partially bridged mesh repair in patients in whom complete midline restoration is impossible via PCS-TAR alone. Nevertheless, we advise most surgeons to perform a small-bridged repair instead of risking increased morbidity by attempting a highly complicated procedure.

Effect of different exercise programs on non-specific chronic low back pain and disability in people who perform sedentary work

BACKGROUND

This study compared the short- and long-term effects of different exercise programs on lumbar muscle function, cross-sectional area of the multifidus muscle, functional disability and low back pain in people who perform sedentary work.

METHODS

A total of 70 volunteer women with sedentary occupations suffering from low back pain were randomized to either the lumbar stabilization exercise program group or the lumbar muscle strengthening exercise program group. All subjects entered the 20-week exercise programs. The measurement of the cross-sectional area of the multifidus muscle was executed by using an ultrasound system, isokinetic peak torque was measured applying an isokinetic dynamometer.

FINDINGS

The results indicated that the 20-week exercise programs reduced low back pain and functional disability. Positive effects for the cross-sectional area of the multifidus muscle, functional disability and low back pain lasted for 4 weeks after the application of lumbar muscle strengthening exercise program and for 12 weeks after the application of lumbar stabilization exercise program. The lumbar muscle strength increased and lasted for 8 weeks after both exercise programs.

INTERPRETATION

The 20-week lumbar stabilization exercise and muscle strengthening exercise programs were efficacious in decreasing LBP and functional disability in people performing sedentary work, however the lumbar stabilization exercise program was more effective, and this effect lasted for 12 weeks after completion of the program.

The use of component separation during abdominal wall reconstruction in contaminated fields: A case-control analysis

BACKGROUND

Component separation technique (CST) allows fascial medialization during abdominal wall reconstruction (AWR). Wound contamination increases the incidence of wound complications, which multiplies the incidence of repair failure. The aim of this study was to compare the impact of CST on AWR outcomes in contaminated fields in comparison to those operations without CST.

METHODS

A prospective, single institution hernia database was queried for patients undergoing AWR with CST and contamination. A case control cohort was identified using propensity score matching.

RESULTS

There were 286 CSTs performed in contaminated cases. After propensity score matching, 61 CSTs were compared to 61 No-CSTs. These groups were matched by defect area (CST:287.1 ± 150.4 vs No-CST:277.6 ± 218.4 cm², p = 0.156), BMI (32.0 ± 7.0 vs 32.2 ± 6.0 kg/m², p = 0.767), diabetes (26.2% vs 32.8%, p = 0.427), and panniculectomy (52.5% vs 36.1%, p = 0.068). Groups had similar rates of wound complications (42.6% vs 40.7%, p = 0.829) and recurrence (4.9% vs 13.1%, p = 0.114).

CONCLUSIONS

The use of CST in the face of contamination is not associated with an increase in wound complications, mesh complications, or recurrence.

Abdominal Wall Reconstruction for Incisional Hernia Optimizes Truncal Function and Quality of Life: A Prospective Controlled Study

OBJECTIVE

The aim of the study was to examine abdominal wall function in patients undergoing abdominal wall reconstruction (AWR) for incisional hernia.

BACKGROUND

The literature on abdominal wall function in patients with incisional hernia is sparse. It has been suggested that AWR leads to improvement in function, but it is unknown whether this is specific to the abdominal wall or due to an improvement in overall physical fitness.

METHODS

We performed a prospective case-control study of 18 consecutive patients with large incisional hernia undergoing AWR with linea alba restoration. Truncal flexion and extension strength, hand grip strength, leg extension power, and quality of life (SF-36 and Carolinas Comfort Scale) were assessed preoperatively and 1 year postoperatively. Patients were compared with a control group of patients with an intact abdominal wall undergoing colorectal resection (n = 18). The study was registered at ClinicalTrials.gov (NCT02011048).

RESULTS

Compared with preoperative measurements, 1-year follow-up after AWR demonstrated an increase of both truncal flexion strength (from mean 505.6 N to 572.3 N, P < 0.001) and truncal extension strength (from 556.7 to 606.0 N, P = 0.005). There was no significant change of either hand grip strength or leg extension power. After AWR, the physical component of overall quality of life improved, whereas the mental component score remained unchanged. In the control group, surgery resulted in a decrease in both truncal flexion and truncal extension.

CONCLUSIONS

AWR for incisional hernia specifically improved long-term abdominal wall muscular function and quality of life.

Giant ventral hernia-relationship between abdominal wall muscle strength and hernia area

Background

Symptoms arising from giant ventral hernia have been considered to be related to weakening of the abdominal muscles. The aim of this study was to investigate the relationship between the area of the abdominal wall defect and abdominal wall muscle strength measured by the validated BioDex system together with a back/abdominal unit.

Methods

Fifty-two patients with giant ventral hernia (>10 cm wide) underwent CT scan, clinical measurement of hernia size and BioDex measurement of muscle strength prior to surgery. The areas of the hernia derived from CT scan and from clinical measurement were compared with BioDex forces in the modalities extension, flexion and isometric contraction. The Spearman rank test was used to calculate correlations between area, BMI, gender, age, and muscle strength.

Result

The hernia area calculated from clinical measurements correlated to abdominal muscle strength measured with the Biodex for all modalities (p-values 0.015–0.036), whereas no correlation was seen with the area calculated by CT scan. No relationship was seen between BMI, gender, age and the area of the hernia.

Discussion

The inverse correlation between BioDex abdominal muscle strength and clinically assessed hernia area, seen in all modalities, was so robust that it seems safe to conclude that the area of the hernia is an important determinant of the degree of loss of abdominal muscle strength. Results using hernia area calculated from the CT scan showed no such correlation and this would seem to concur with the results from a previous study by our group on patients with abdominal rectus diastasis. In that study, defect size assessed clinically, but not that measured by CT scan, was in agreement with the size of the diastasis measured intra-operatively.

The point at which the area of a hernia begins to correlate with loss of abdominal wall muscle strength remains unknown since this study only included giant ventral hernias.

Effects of a 16-week Pilates exercises training program for isometric trunk extension and flexion strength

OBJECTIVE

To evaluate the effects of Pilates exercises designed to improve isometric trunk extension and flexion strength of muscles in women with chronic low back pain (cLBP).

PARTICIPANTS

Female volunteers with cLBP were divided into an experimental group (EG; n = 27) and a control group (CG; n = 27).

INTERVENTION

Pilates exercises were performed twice per week by the EG; the duration of each session was 60 min. The program lasted for 16 weeks; thus patients underwent a total of 32 exercise sessions.

RESULTS

The maximum isometric waist bending strength of the EG had improved significantly (p = 0.001) after 16 weeks of the Pilates program. The results of trunk flexion muscle endurance tests significantly depended on the trunk extension muscle endurance before the intervention, and at 1 month (r = 0.723, p < 0.001) and 2 months (r = 0.779, p < 0.001) after the Pilates exercise program. At the end of the 16-week exercise program, cLBP intensity decreased by 2.01 ± 0.8 (p < 0.05) in the EG, and this reduction persisted for 1 month after completion of the program.

CONCLUSIONS

At 1 and 2 months after cessation of the Pilates exercise program the pain intensified and the functional state deteriorated much faster than the maximum trunk muscle strength. Therefore, it can be concluded that, to decrease pain and improve functional condition, regular exercise (and not only improved strength and endurance) is required. We established that, although the 16-week lumbar stabilization exercise program increased isometric trunk extension and flexion strength and this increase in strength persisted for 2 months, decreased LBP and improved functional condition endured for only 1 month.

Reliability of muscle strength assessment in chronic post-stroke hemiparesis: a systematic review and meta-analysis

BACKGROUND

Muscle weakness is the main cause of motor impairment among stroke survivors and is associated with reduced peak muscle torque.

OBJECTIVE

To systematically investigate and organize the evidence of the reliability of muscle strength evaluation measures in post-stroke survivors with chronic hemiparesis.

DATA SOURCES

Two assessors independently searched four electronic databases in January 2014 (Medline, Scielo, CINAHL, Embase).

STUDY SELECTION

Inclusion criteria comprised studies on reliability on muscle strength assessment in adult post-stroke patients with chronic hemiparesis.

DATA EXTRACTION

We extracted outcomes from included studies about reliability data, measured by intraclass correlation coefficient (ICC) and/or similar. The meta-analyses were conducted only with isokinetic data.

RESULTS

Of 450 articles, eight articles were included for this review. After quality analysis, two studies were considered of high quality. Five different joints were analyzed within the included studies (knee, hip, ankle, shoulder, and elbow). Their reliability results varying from low to very high reliability (ICCs from 0.48 to 0.99). Results of meta-analysis for knee extension varying from high to very high reliability (pooled ICCs from 0.89 to 0.97), for knee flexion varying from high to very high reliability (pooled ICCs from 0.84 to 0.91) and for ankle plantar flexion showed high reliability (pooled ICC = 0.85).

CONCLUSION

Objective muscle strength assessment can be reliably used in lower and upper extremities in post-stroke patients with chronic hemiparesis.

Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation

PURPOSE

Anterior component separation (ACS) with external oblique release for ventral hernia repair has a recurrence rate up to 32%. Hernia recurrence after prior ACS represents a complex surgical challenge. In this context, we report our experience utilizing posterior component separation with transversus abdominis muscle release (PCS/TAR) and retromuscular mesh reinforcement.

METHODS

Patients with a history of recurrent hernia following ACS repaired with PCS/TAR were retrospectively identified from prospective databases collected at two large academic institutions. Patient demographics, hernia characteristics (using CT scan) and outcomes were evaluated.

RESULTS

Twenty-nine patients with a history of ACS developed 22 (76%) midline, 3 (10%) lateral and 4 (14%) concomitant recurrences. Contamination was present in 11 (38%) of cases. All were repaired utilizing a PCS/TAR with retromuscular mesh placement (83% synthetic, 17% biologic) and fascial closure. Wound morbidity consisted of 13 (45%) surgical site occurrences including 8 (28%) surgical site infections. Five (17%) patients required 90-day readmission, and two (7%) were related to wound morbidity. One organ space infection with frank spillage of stool resulted in the only instance of mesh excision. This case also represents the only instance of recurrence (3%) with a mean follow-up of 11 (range 3-36) months.

CONCLUSION

Patients with a history of an ACS who develop a recurrence represent a challenging clinical scenario with limited options for surgical repair. A PCS/TAR hernia repair achieves acceptable outcomes and may in fact be the best approach available.

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.

Functional abdominal wall reconstruction improves core physiology and quality-of-life

INTRODUCTION

One of the goals of modern ventral hernia repair (VHR) is restoring the linea alba by returning the rectus muscles to the midline. Although this practice presumably restores native abdominal wall function, improvement of abdominal wall function has never been measured in a scientific fashion. We hypothesized that a dynamometer could be used to demonstrate an improvement in rectus muscle function after open VHR with restoration of the midline, and that this improvement would be associated with a better quality-of-life.

METHODS

Thirteen patients agreed to dynamometric analysis before and 6 months after an open posterior component separation (Rives-Stoppa technique complimented with a transversus abdominis muscle release) and mesh sublay. Analysis done using a dynamometer (Biodex 3, Corp, Shirley, NY) included measurement of peak torque (PT; N*m) and PT per bodyweight (BW; %) generated during abdominal flexion in 5 settings: Isokinetic analysis at 45°/s and 60°/s as well as isometric analysis at 0°, -15°, and +15°. Power (W) was calculated during isokinetic settings. Quality-of-life was measured using our validated HerQles survey at the time of each dynamometric analysis.

RESULTS

Thirteen patients (mean age, 54 ± 9 years; mean body mass index, 31 ± 7 kg/m(2)) underwent repair with restoration of the midline using the aforementioned technique. Mean hernia width was 12.5 cm (range, 5-19). Improvements in PT and PT/BW were significant in all 5 settings (P < .05). Improvement in power during isokinetic analyses at 45°/s and 60°/s was also significant (P < .05). All patients reported an improvement in quality-of-life, which was associated positively with each dynamometric parameter.

CONCLUSION

Restoration of the linea alba during VHR is associated with improved abdominal wall functionality. Analysis of rectus muscle function using a dynamometer showed statistical improvement by isokinetic and isometric measurements, all of which were associated with an improvement in quality-of-life.

[Indications for laparoscopic treatment of large incisional hernias]

Hernia surgeons and patients have learned to appreciate the advantages of minimally invasive laparoscopic procedures. After overcoming the early learning curve phase, smaller wound surface areas, shorter operation times and briefer hospital stays have become routine. Severe surgery-related complications are rare. Patients with poor risk profiles (e.g. age >70 years, BMI >30 and nicotine consumption) profit especially from these advantages. This positive picture is clouded, however, by the need for an intraperitoneal mesh and specifically by the unchanged recurrence rate. The latter is not significantly lowered even by laparoscopic intraperitoneal on-lay mesh (laparoscopic IPOM) procedures. The current literature shows that irrespective of surgical technique, e.g. retromuscular mesh or laparoscopic IPOM, the risk profile and size of the hernia defect are independent factors that determine the prognosis for recurrence. While a cure of incisional hernia is no longer the only goal, the new indication scenario has two main goals: (a) for young patients at low risk or in patients for whom functional and morphological reconstruction of the abdominal wall are of primary importance, an open retromuscular mesh procedure is indicated (despite the higher morbidity) and (b) for older patients and chiefly for patients with a complex risk profile for whom treatment of the ventral hernia symptoms is paramount, laparoscopic procedures are indicated (due to the lower morbidity). This algorithm assumes that the treating surgeons have the requisite expertise and is discussed using the examples of four complex case reports.

Laparoscopic bridging vs. anatomic open reconstruction for midline abdominal hernia mesh repair [LABOR]: single-blinded, multicenter, randomized, controlled trial on long-term functional results

BACKGROUND

Re-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an "open" access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule.

METHODS AND DESIGN

The LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively.

DISCUSSION

The study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon's experience.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN93729016.

Long-term outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia

OBJECTIVE

Long-term quality of life and body image of patients with abdominal wound dehiscence were assessed.

METHODS

Thirty-seven patients with abdominal wound dehiscence from a prospectively followed cohort of 967 patients (2007-2009) were reviewed. Patients completed the Short Form 36 quality of life questionnaire and Body Image Questionnaire and participated in semi-structured telephone interviews. For each patient, four controls were matched by age and gender. Analyses were adjusted for age, gender, comorbidity, and follow-up length.

RESULTS

Of the 37 patients with abdominal wound dehiscence, 23 were alive after a mean follow-up of 40 months (range 33-49 months). Nineteen patients developed incisional hernias (83 %). Patients with abdominal wound dehiscence reported significantly lower scores for physical and mental component summaries (p = 0.038, p = 0.013), general health (p = 0.003), mental health (p = 0.011), social functioning (p = 0.002), and change (p = 0.034). No differences were found for physical functioning (p = 0.072), role physical (p = 0.361), bodily pain (p = 0.133), vitality (p = 0.150), and role emotional (p = 0.138). Patients with abdominal wound dehiscence reported lower body image scores (median 16.5 vs. 18, p = 0.087), cosmetic scores (median 13 vs. 16, p = 0.047), and total body image scores (median 30 vs. 34, p = 0.042).

CONCLUSIONS

At long-term follow-up, patients with abdominal wound dehiscence demonstrated a high incidence of incisional hernia, low body image, and low quality of life.

Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess abdominal wall function

BACKGROUND

Success of a surgical intervention is often measured by hard clinical outcomes. In ventral hernia repair (VHR) these include wound morbidity and hernia recurrence. These outcomes fail to account for a surgical intervention's effect on a patient's quality of life (QofL). Our objective was to design a hernia-specific QofL instrument with a focus on abdominal wall function, evaluate its measurement properties, and assess the impact of VHR on QofL using this new instrument.

STUDY DESIGN

A 16-question QofL survey tool, HerQLes, was constructed. Patients presenting for elective VHR completed the survey. Rasch modeling was used to evaluate the items; fit statistics, person-item mapping, separation index, and reliability were examined. Associations between baseline characteristics and QofL were assessed.

RESULTS

Eighty-eight patients completed the survey before assessment for VHR. Mean age was 57.2 years (±12.4 years), mean American Society of Anesthesiologists score was 2.8 (±0.5), and mean body mass index was 34.9 kg/m(2) (±9.3 kg/m(2)). Based on Rasch modeling, 12 of 16 items met model fit criteria. The 4 poorly fitting items were eliminated from further analysis. The 12 items retained have good internal consistency reliability (0.86). On a 0- to 100-point scale, mean QofL score was 47.2 (±15.6). Patients with higher grade hernias had lower HerQLes scores (p = 0.06). Patients showed significant improvement in abdominal wall function and QofL 6 months after VHR (p < 0.01).

CONCLUSIONS

Quality-of-life is an important component of surgical management of ventral hernias. The 12-question QofL survey, HerQLes, is reliable and valid. At baseline, patients with more complex hernias tended to have a decreased abdominal wall function and QofL. Six months after surgical repair, HerQLes scores change in the predicted direction. We believe HerQLes is potentially a valuable tool to assess patient-centered abdominal wall functional improvements after VHR.