Transabdominal midline reconstruction by minimally invasive surgery: technique and results

Mini-invasive surgery for diastasis recti: an overview on different approaches

Diastasis recti abdominis (DRA) is an acquired condition defined by a widening of the linea alba exceeding 2 cm and the subsequent separation between the two medial margins of the rectus muscles, accompanied by a laxity of the ventral abdominal muscles, and often by ventral midline hernias. It is a quite common problem in women after pregnancy. In addition to the aesthetic implications resulting from the swelling of the anterior abdominal wall in the case of increased pressure within the abdominal cavity, DRA leads to several physical functional disorders, including muscle weakness, prolapses of the pelvic organs, urinary and fecal incontinence, low back and pelvic pain and sexual dysfunction. The management of diastasis recti can be conservative, with physiotherapy and specific physical exercises, but, especially in case of concomitant hernia, surgery can be considered as the first choice of treatment in order to restore the midline and repair the hernia. Through recent years, a large amount of mini-invasive surgical techniques has been proposed, approaching the abdominal differently, and to date there is still lack of evidence on the optimal choice for surgeons and patients. So, the present review aims to give the reader an overview on the different techniques proposed, focusing on the three main categories of approaches (pre-aponeurotic, retro-muscular and pre-peritoneal), their specific features and results, with a view on the newly proposed robotic approaches that can theoretically reproduce each single technique.

Switching from robotic-assisted extended transabdominal preperitoneal (eTAPP) to totally extraperitoneal (eTEP) hernia repair for umbilical and epigastric hernias

Our study aimed to assess the safety and effectiveness of the robotic-assisted extended totally extraperitoneal (eTEP) repair compared to transabdominal preperitoneal (eTAPP) repair with a suprapubic trocar insertion to treat umbilical and epigastric hernias. On a prospectively maintained database, we identified patients who underwent either eTEP or eTAPP for treating umbilical and epigastric hernias. During the study period, 53 patients were included, 32 in the eTEP group and 21 in the eTAPP group. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male, and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). The operative time for eTEP was slightly shorter than for eTAPP (106 ± 43 min vs. 126 ± 74 min, p = 0.232). Postoperatively, only one case of bleeding and one seroma were recorded. No complication occurred during a mean follow-up of 11.3 ± 6.4 months in the eTEP group and 20.5 ± 9.7 months in the eTAPP group. In conclusion, our study showed that the eTEP with suprapubic approach was safe and feasible in the treatment of epigastric and umbilical hernias. According to our experience, shorter operative time, integrity of the posterior layers and increased overlap size are the main surgical reasons of switching from eTAPP to eTEP.

Clinical Outcomes of Enhanced Recovery After Surgery Program in Elderly Patients Undergoing Transabdominal Preperitoneal

Background: Enhanced recovery after surgery (ERAS) protocol is an effective evidence-based multidisciplinary protocol to optimize the postsurgical recovery process through perioperative interventions. The aim of the present study was to evaluate the effects of ERAS program on operation-related indicators, complications, pain, and quality of life in patients older than 60 years undergoing the transabdominal preperitoneal (TAPP) approach. Methods: This was a retrospective study of prospectively collected data from a single institution. A total of 160 elderly patients who underwent TAPP were divided into two groups: 80 patients in the ERAS group from January 2019 to December 2020, and 80 patients in the non-ERAS group from January 2021 to December 2022 in the non-ERAS group, and the groups were managed with the ERAS protocol and conventional management, respectively. We compared differences in operation-related indicators, complications, pain, and quality of life between the two groups. Results: Operation-related indicators (exhaust time, postoperative eating time, time to first ambulation, hospitalization cost, and postoperative hospital stay) and early postoperative pain of the ERAS group were superior to those of the non-ERAS group, and the difference had statistical significance (P < .05). More importantly, our results demonstrated that compared with the non-ERAS group, the application of ERAS in inguinal hernia patients may reduce postoperative complications (urinary retention, chronic pain) and improve quality of life. Conclusion: The ERAS program might provide the efficiency and safety approach to optimize clinical outcomes in the elderly patients older than 60 years undergoing TAPP approach.

Stapled fascial suture: ex vivo modeling and clinical implications

BACKGROUND

Recently, in the field of abdominal wall repair surgery, some minimally invasive procedures introduced the use of staplers to provide a retromuscular prosthetic repair. However, to the knowledge of the authors, there are little data in the literature about the outcomes of stapled sutures adoption for midline reconstruction. This study aims to investigate the biomechanics of stapled sutures, simple (stapled), or oversewn (hybrid), in comparison with handsewn suture. From the results obtained, we tried to draw indications for their use in a clinical context.

METHODS

Human cadaver fascia lata specimens, sutured (handsewn, stapled, or hybrid) or not, underwent tensile tests. The data on strength (maximal stress), ultimate strain (deformability), Young's modulus (rigidity), and dissipated specific energy (ability to absorb mechanical energy up to the breaking point) were recorded for each type of specimens and analyzed.

RESULTS

Stapled and hybrid suture showed a significantly higher strength (handsewn 0.83 MPa, stapled 2.10 MPa, hybrid 2.68 MPa) and a trend toward a lower ultimate strain as compared to manual sutures (handsewn 344%, stapled 249%, hybrid 280%). Stapled and hybrid sutures had fourfold higher Young's modulus as compared to handsewn sutures (handsewn 1.779 MPa, stapled 7.374 MPa, hybrid 6.964 MPa). Handsewn and hybrid sutures showed significantly higher dissipated specific energy (handsewn 0.99 mJ-mm3, stapled 0.73 mJ-mm3, hybrid 1.35 mJ-mm3).

CONCLUSION

Stapled sutures can resist high loads, but are less deformable and rigid than handsewn suture. This suggests a safer employment in case of small defects or diastasis (< W1 in accord to EHS classification), where the presumed tissutal displacement is minimal. Oversewing a stapled suture improves its efficiency, becoming crucial in case of larger defects (> W1 in accord to EHS classification) where the expected tissutal displacement is maximal. Hybrid sutures seem to be a good compromise.

Favourable outcomes after Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Non-Complex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-Analysis

OBJECTIVE

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

SUMMARY BACKGROUND DATA

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For non-complex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

METHODS

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

RESULTS

Ninety-three studies representing 12440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% (95%CI: 2.2-4.2%, n = 11049) after minimally 12 months and 4.1%, (95%CI: 2.9-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2-6.4%, n = 4891) and 5.5% (95%CI: 4.4-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (OR: 0.27, 95%CI: 0.15-0.51, p < 0.001) and equal recurrence rates compared to intraperitoneal onlay (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03-3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8-2.8%, n = 982), albeit based on non-randomized studies.

CONCLUSIONS

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except surgical site infection. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

Effect of Laparoscopic Total Extraperitoneal Umbilical Hernia Repair on Incision Infection, Complication Rate, and Recurrence Rate in Patients with Umbilical Hernia

The aim of this study is to clarify the influence of laparoscopic total extraperitoneal umbilical hernia repair on incision infection, complication rate, and recurrence rate in patients with an umbilical hernia (UH). Sixty-seven UH patients referred to our hospital from June 2017 to June 2019 were selected as the research participants. Thirty-six patients in the research group (RG) were treated with laparoscopic total extraperitoneal umbilical hernia repair, and the other 31 cases in the control group (CG) were treated with traditional umbilical hernia repair. The two cohorts of patients were compared with respect to the curative effect after treatment; intraoperative blood loss, operation time, postoperative pain time, ambulation time, and hospital stay; incidence of complications; pain severity (VAS) before and after operation; sleep quality (PSQI) before and after operation; patient satisfaction after treatment; and recurrence half a year after discharge. The RG presented a higher effective treatment rate (P < 0.05), less intraoperative blood loss, operation time, postoperative pain time, ambulation time, and hospital stay, as well as lower incidence of complications than the CG (P < 0.05). VAS and PSQI scores differed insignificantly between the two cohorts of patients before treatment (P > 0.05) but reduced after treatment, with lower VAS and PSQI scores in the RG than in the CG (P < 0.05). The number of people who were highly satisfied, as investigated by the satisfaction survey, was higher in the RG than in the CG, while the recurrence rate of prognosis was lower than that in the CG (P < 0.05). Laparoscopic total extraperitoneal umbilical hernia repair is effective for UH patients and can validly reduce the incidence of complications and recurrence rate, which has huge clinical application value.

A Detailed History of Retromuscular Repairs for Ventral Hernias: A Story of Surgical Innovation

BACKGROUND

We performed a historical review of events concerning retromuscular hernia repairs over the last two centuries. This may shed light on surgical innovators and their novel techniques that have evolved into current practices.

METHODS

Literature reviews of notable surgeons in the subspecialty were reviewed. Historical context was obtained by personal communication with contemporary surgeons who witnessed changes in established techniques firsthand.

RESULTS

Even though retromuscular repairs are the central theme of this exercise, it is important to note several adjacent events which steered surgical progress. The status of hernia surgery today is the result of the work of several pioneers separated by time and distance.

CONCLUSIONS

It may be important to understand the circumstances that have propelled past surgical breakthroughs to stimulate future progress.

Innovations in surgical treatment of rectus abdominis diastasis: a review of mini-invasive techniques

Abdominal rectus diastasis (RD) is characterized by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This condition is associated with bulging of abdominal content, and it is mostly acquired during pregnancy or obesity. Symptoms include pain and discomfort in the abdomen, musculoskeletal and uro-gynecological problems in addition to negative body image and impaired quality of life. In this review we present current knowledge on the novel surgical mini-invasive techniques for treatment of RD. The aim of our study is to discuss the use of a standard classification to define pathological RD and possible indications for a minimally invasive repair, considering complications, patients' satisfaction and recurrence rate. A PubMed search of the literature has been conducted in January 2020 including the most recent articles using the following criteria among the interventions for RD: mini-invasive surgery, laparoscopic, endoscopy and robotic procedures. Minimally invasive surgical treatment options for rectus diastasis are poorly investigated and indications for repair are still debated. Guidelines are mandatory to standardize surgical management of RD.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature.

METHODS

A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic.

RESULTS

In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification.

CONCLUSION

Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Stapled VTEP (sVTEP), diastasis and the "swollen abdomen"

BACKGROUND

In the VTEP series, some patients declared that their abdomen was "somewhat swollen", and the authors suggested that this might be related to disruption of the posterior sheath due to the crossing. Following this observation, we decided to evaluate the systematic repair of the posterior sheath.

METHODS

In 50 consecutive patients operated for ventral hernias, the VTEP procedure was modified, using the linear stapler to perform simultaneous division and closure of the posterior sheath. Perioperative data and short-term results were prospectively assessed.

RESULTS

Six (12%) complications occurred: one hematoma, one sudden death at home five days after surgery in a man with history of cardiac disease, and 4 cases of dehiscence of the staple line, which were successively reoperated by suture of the gap and posterior sheath release incision (PSR). With a mean follow-up of 7.5 months (4-12) there were no recurrences and 2 cases of "swollen abdomen", in patients who undergone PSR. The "swollen abdomen" did not occur when the posterior sheath was repaired without PSR. Preoperative diastasis bulging present in 11 cases, was totally or partially corrected in 8 and 1 cases, respectively, and unchanged in 2 cases.

CONCLUSION

The sVTEP procedure, can contribute to prevent the swollen abdomen and to diastasis correction. The PSR can prevent staple line disruption or permit tension-free repair of the dehiscence, but then, the newly created lateral gaps can finally entail the same drawback. Search for the best solution to treat the gap in the posterior sheath requires further studies.

Robot-assisted Treatment of Epigastric Hernias With a Suprapubic Approach

BACKGROUND

Robot-assisted ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are placed laterally to meet the distance from the fascial defect. The aim of our study is to report our experience of epigastric hernia treatment with trocar insertion in the suprapubic region.

MATERIALS AND METHODS

On a prospectively collected dataset on robot-assisted surgery, patients treated for epigastric hernias with suprapubic approach were identified. Demographic and clinical data were collected and analyzed.

RESULTS

Twelve patients were selected. Median age was 58.5 years [interquartile range (IQR): 47.8 to 67.3 y]; 4 patients were male (33.3%) and the median body mass index was 23.9 kg/m2 (IQR: 22.3 to 26.2 kg/m2). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR: 13.75 to 31.0 mm); median larger mesh diameter was 13.5 cm (IQR: 9.5 to 15.0 cm); and median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication or conversion to open surgery occurred. Postoperatively, 2 patients presented a seroma and median length of hospital stay was 2.0 days (IQR: 1.75 to 3 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 4 to 29 mo).

CONCLUSIONS

In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.

[Minimally invasive correction of anatomical features of anterior abdominal wall and ventral hernias]

Conventional «open» procedures for ventral hernias and diastasis recti are widely known, used everywhere and have a great number of author's improvements related to surgeon's experience, availability of modern information, equipment and materials. K. LeBlanc and W. Booth (1993) reported IPOM-method with non-adhesive coating that is considered a milestone in surgery of anterior abdominal wall and ventral hernia. This technique has gained recognition among surgeons around the world due to its technical simplicity, minimal invasiveness and high reproducibility. However, certain disadvantages of this technique have been shown over the past time that justified advisability of searching for another methods of anterior abdominal wall reinforcement. Thus, E-Milos, LIRA, TESAR, eTEP, REPA, TARM, TARUP techniques are currently available. This review is devoted to technical features of these techniques, their potential advantages and disadvantages.

Prospective observational study of abdominal wall reconstruction with THT technique in primary midline defects with diastasis recti: clinical and functional outcomes in 110 consecutive patients

INTRODUCTION

Surgical treatment of diastasis recti is still a matter of debate. Open approaches such as abdominoplasty, which offer the possibility to combine reparation of the diastasis with abdominal cosmetic surgery, are challenged by the emerging less-invasive laparoscopic or robotic techniques that offer shorter recovery for patients. However, evidence in favour of one of the two approaches concerning both short- and long-term complications and functional results is still lacking. In this paper, we analysed clinical and functional results of a new endo-laparoscopic technique for midline reconstruction (THT technique) in patients with primary abdominal wall defects associated with diastasis recti.

METHODS

Prospective observational study on 110 consecutive patients was submitted to endo-laparoscopic reconstruction of the abdominal wall with linear staplers. Morbidity and relapse rates with clinical and radiological follow-up were recorded at 1, 6, 12, and 24 months after the operation. Data regarding the impact of surgery on patients' quality of life (EuraHSQol) on chronic low back pain (Oswestry Disability Index, ODI) and urinary stress incontinence (Incontinence Severity Index, ISI) were gathered.

RESULTS

After a mean follow-up of 14 months, the morbidity rate was 9.1% and no recurrences were recorded. 6-month follow-up ultrasound showed a rectus muscles mean distance of 6.7 mm; EuraHSQol, ODI, and ISI scores significantly improved in 93%, 77%, and 63% of the cases, respectively.

CONCLUSIONS

The THT technique proved to be a feasible, safe, and effective alternative for corrective surgery of primary midline hernias associated with diastasis recti. Short- and mid-term results are encouraging but need to be confirmed by further studies with longer follow-up. The achieved midline reconstruction offers a significant improvement of patients' perceived quality of life through reduction of abdominal wall pain, bulging, low back pain, and urinary stress incontinence.

Endoscopic totally extraperitoneal approach (TEA) technique for primary ventral hernia repair

Background

Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space).

Methods

Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall.

Results

All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85–145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1–3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10–27 months).

Conclusion

In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

Ventral hernia repair by totally extraperitoneal approach (VTEP): technique description and feasibility study

BACKGROUND

The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results.

METHODS

The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed.

RESULTS

98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1-50) cm² and 225 (50-500) cm², respectively. The mean operation duration was 75 (30-270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0-8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1-15) days and 11.5 (1-30) days, respectively.

CONCLUSION

Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies.

Acronyms Use in Abdominal Wall Reconstruction: Introduction to a New Language

BACKGROUND

The use of acronyms in medicine is widespread, aiming to simplify and condense communication. Online communication in social media platforms seems to enhance the use of acronyms, but their efficiency in message delivery may be negated by their abundance and unfamiliarity, causing more confusion than clarity. We analyzed the use of acronyms in a closed Facebook group dedicated to abdominal wall reconstruction (AWR), as the rapid recent development of this field has resulted in many new acronyms. Our aim was to classify the different acronyms and create a public reference.

METHODS

The International Hernia Collaboration, a hernia-related Facebook group, now communicating more than 7500 surgeons from 99 countries, was studied, by extracting acronyms used since its inception in 2012. Acronyms were categorized and interpreted, to create a small dictionary comprised of several tables.

RESULTS

Commonly used acronyms were identified, as well as commonly used prefixes that modify the acronyms' meaning. Tables were created, classifying acronyms by their subject: 1.Anatomy2.Diseases and clinical conditions3.Techniques and materials.

CONCLUSION

The use of acronyms increased in social media-based communication. Aiming to simplify the language, the inflation of terms may have achieved the opposite, by adding a multitude of unfamiliar and confusing terms. We have created a public reference for AWR-related acronyms. Limiting the liberal creation of new acronyms is recommended, especially in a rapidly changing field as AWR.

Classification of Rectus Diastasis-A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS)

Introduction: Recently, the promising results of new procedures for the treatment of rectus diastasis with concomitant hernias using extraperitoneal mesh placement and anatomical restoration of the linea alba were published. To date, there is no recognized classification of rectus diastasis (RD) with concomitant hernias. This is urgently needed for comparative assessment of new surgical techniques. A working group of the German Hernia Society (DHG) and the International Endohernia Society (IEHS) set itself the task of devising such a classification.

Materials and Methods: A systematic search of the available literature was performed up to October 2018 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library. A meeting of the working group was held in May 2018 in Hamburg. For the present analysis 30 publications were identified as relevant.

Results: In addition to the usual patient- and technique-related influencing factors on the outcome of hernia surgery, a typical means of rectus diastasis classification and diagnosis should be devised. Here the length of the rectus diastasis should be classified in terms of the respective subxiphoidal, epigastric, umbilical, infraumbilical, and suprapubic sectors affected as well as by the width in centimeters, whereby W1 < 3 cm, W2 = 3− ≤ 5 cm, and W3 > 5 cm. Furthermore, gender, the concomitant hernias, previous abdominal surgery, number of pregnancies and multiple births, spontaneous birth or caesarian section, skin condition, diagnostic procedures and preoperative pain rate and localization of pain should be recorded.

Conclusion: Such a unique classification is needed for assessment of the treatment results in patients with RD.

Endo-laparoscopic reconstruction of the abdominal wall midline with linear stapler, the THT technique. Early results of the first case series

Background

Midline primary hernias represent one of the most frequent abdominal wall defects in the adult population and in almost half of the cases they are associated with a rectus abdominis diastasis (RAD). Despite the high incidence of these defects there is currently no consensus in the literature on what is the preferred surgical technique for treatment. In this paper we present the first case series treated with an innovative technique that aims to repair the defects of the midline and RAD, while combining the advantages of the sublay Rives-Stoppa technique with those of the minimally-invasive surgery.

Methods

Between January 2018 and May 2018, 14 patients underwent endo-laparoscopic reconstruction of the midline. The surgery was performed under general anaesthesia through a 4 cm periumbilical incision with single port technique. The rectus abdominis sheaths were joined together and sutured lengthwise using a linear stapler. A tailor-made synthetic prosthesis was positioned in the retromuscular space.

Results

All cases had RAD with a mean width of 5.3 cm in the supraumbilical space. None of the surgeries needed laparotomic conversion. The average duration of the surgery was 80 min. The hospitalization was in all cases one day. The average follow-up period was 6 months. Neither recurrences, nor major or minor complications have been reported to date.

Conclusion

Our THT is a feasible technique, easily reproducible, and effective in the repair of primary defects of the midline and RAD, which greatly reduces the operating times and hospitalization allowing a quick return to active life.

•

The THT procedure is a surgical technique for repair of the abdominal wall midline hernias and rectus abdominis diastasis.

•

The THT procedure combines the advantages of endoscopic single port surgery with those of a retromuscular prosthetic reconstruction.

•

The THT procedure strongly reduces costs and operative times if compared to lap/robotic surgery while allows to avoid the complication risks related to a large laparotomy.

Single-incision laparoscopic preperitoneal mesh repair of supra-pubic incisional hernia: A case report

Introduction

Repair of supra-pubic incisional hernia is still challenging because of the highest pressure at the lower abdominal wall in the erect position. Recently, laparoscopic preperitoneal mesh repair has been gradually reported.

Case presentation

A 77-year-old woman underwent single-incision laparoscopic preperitoneal mesh repair under a diagnosis of a supra-pubic incisional hernia, measuring 7 × 4 cm. A single, 2.5-cm, intraumbilical incision was made, followed by creation of the preperitoneal space. Then, the posterior rectus sheath and peritoneum were opened, and laparoscopic exploration was performed. After dissection of the supra-pubic hernia content, the tube for degassing the abdominal cavity was inserted into the abdominal cavity, and the peritoneum and the posterior sheath were closed. The preperitoneal space was dissected gradually, and circular dissection of the hernia sac was performed. The proximal sac (peritoneum) was sutured continuously. A 15 × 10 cm mesh was placed in the preperitoneal space and fixed securely with absorbable tacks at the pubic bone, Cooper's ligament, and the rectus abdominis muscle, respectively. After degassing the preperitoneal space, a second laparoscopic exploration was performed to confirm the secure suture of the peritoneum and no injury of the abdominal organs. At 4-month follow-up, the patient remained well with no signs of recurrence.

Discussion

Single-incision laparoscopic preperitoneal mesh repair could minimize the recurrence of supra-umbilical incisional hernia and perioperative complications.

Conclusion

Single-incision laparoscopic preperitoneal mesh repair, offering good cosmetic results, might be useful for repair of supra-pubic incisional hernia.

The effect of thymoquinone coating on adhesive properties of polypropylene mesh

BACKGROUND

An incisional hernia is a common complication following abdominal surgery. Polypropylene mesh is frequently used in the repair of such defects and has nearly become the standard surgical treatment modality. Though they are very effective in reducing recurrence, mesh materials exhibit a strong stimulating effect for intraabdominal adhesion. The thymoquinone (TQ) extracted from Nigella sativa seeds has potential medical properties. TQ has anti-inflammatory, antioxidant and antibacterial properties. The aim of this study is to coat polypropylene mesh with TQ in order to investigate the effect of surface modification on intraabdominal adhesions.

METHODS

TQ-coated polypropylene mesh material was tested for cytotoxicity, contact angle, surface spectroscopy, TQ content, sterility, and electron microscopic surface properties. An experimental incisional hernia model was created in study groups, each consisting of 12 female Wistar rats. The defect was closed with uncoated mesh in control group, with polylactic acid (PLA) coated mesh and PLA-TQ coated mesh in study groups. Adhesion scores and histopathologic properties were evaluated after sacrifice on postoperative 21th day.

RESULTS

Granuloma formation, lymphocyte and polymorphonuclear leukocyte infiltration, histiocyte fibroblast and giant cell formation, capillary infiltration, collagen content were significantly reduced in the PLA-TQ coated mesh group (p < 0.05). Though not statistically significant, likely due to the limited number of study animals, adhesion formation was also reduced in the PLA-TQ coated mesh group (p: 0.067).

CONCLUSION

TQ coated mesh is shown to reduce adhesion formation and TQ is a promising coating material for mesh surface modification.