Outcomes of transversus abdominis release in non-elective incisional hernia repair: a retrospective review of the Americas Hernia Society Quality Collaborative (AHSQC)

Mapping the therapeutic landscape in emergency incisional hernia: a scoping review

PURPOSE

Incisional hernias (IH) represent common complications following abdominal surgeries, with emergency repair associated with increased morbidity and mortality. This scoping review aimed to map the existing literature on emergency incisional hernia repair, identify research gaps, and inform future guideline development.

METHODS

A comprehensive literature search was conducted in PubMed MEDLINE and SCOPUS for studies published between January 2000 and August 2024. Articles addressing any aspect of emergency incisional hernia repair in adults were included. Data extraction focused on study characteristics, patient demographics, surgical approaches, and outcomes.

RESULTS

Of 801 unique articles identified, 73 met the inclusion criteria. Most were cohort studies (73.97%), with only one randomized trial. The primary areas of interest were repair methods (47.95%), operative outcomes (31.51%), risk assessment (16.44%), and diagnosis (5.48%). Pooled analysis revealed a predominantly female (63%), elderly (mean age 62.3 years), and comorbid patient population. The most frequent study endpoints were readmission (18%), surgical site infection (12%), reoperation (8%), and mortality (4%). Significant heterogeneity was observed in defect characterization and surgical techniques.

CONCLUSION

This review highlights a paucity of randomized studies guiding emergency incisional hernia management. Key issues identified include inconsistent definitions of emergency presentation, limited data on hernia characteristics, and a lack of standardized outcome reporting. Future research should focus on developing a unified classification system for emergency incisional hernias, evaluating the role of imaging in decision-making, and conducting comparative studies on various treatment strategies across different clinical scenarios.

Outcomes after open posterior component separation via transversus abdominis release (TAR) for incisional hernia repair. A systematic review and meta-analysis

PURPOSE

Given its potential advantages, open Transversus Abdominis Release (oTAR) has been proposed as a durable solution for complex AWR. However, its applicability in different scenarios remains uncertain. We aimed to analyze the current available evidence and determine surgical outcomes after oTAR.

METHODS

We performed a systematic electronic search on oTAR in PubMed/Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Postoperative morbidity and recurrence rates were included as primary endpoints and Quality of life (QoL) was included as secondary endpoint. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) between all studies.

RESULTS

A total of 22 studies with 4,910 patients undergoing oTAR were included for analysis. Mean hernia defect and mesh area were 394 (140-622) cm2 and 1065 (557-2206) cm2, respectively. Mean follow-up was 19.7 (1-32) months. The weighted pooled proportion of recurrence, overall morbidity, surgical site occurrences (SSO), surgical site infection (SSI), surgical site occurrences requiring procedural intervention (SSOPI), major morbidity and mortality were: 6% (95% CI, 3-10%), 34% (95% CI, 26-43%), 22% (95% CI, 16-29%), 11% (95% CI, 8-16%), 4% (95% CI, 3-7%), 6% (95% CI, 4-10%) and 1% (95% CI, 1-2%), respectively. A significant improvement in QoL after oTAR was reported among studies.

CONCLUSION

Open TAR is an effective technique for complex ventral hernias as it is associated with low recurrence rate and a significant improvement in QoL. However, the relatively high morbidity rates observed emphasize the necessity of further patients' selection and optimization to improve outcomes.

Limitations of Transversus Abdominis Release (TAR)-Additional Bridging of the Posterior Layer And/Or Anterior Fascia Is the Preferred Solution in Our Clinical Routine If Primary Closure is Not Possible

Background: By separating the abdominal wall, transversus abdominis release (TAR) permits reconstruction of the abdominal wall and the placement of large mesh for many types of hernias. However, in borderline cases, the mobility of the layers is inadequate, and additional bridging techniques may be required for tension-free closure. We now present our own data in this regard. Patients and Methods: In 2023, we performed transversus abdominis release on 50 patients as part of hernia repair. The procedures were carried out using open (n = 25), robotic (n = 24), and laparoscopic (n = 1) techniques. The hernia sac was always integrated into the anterior suture and, in the case of medial hernias, was used for linea alba reconstruction. Results: For medial hernias, open TAR was performed in 22 cases. Additional posterior bridging was performed in 7 of these cases. The ratio of mesh size in the TAR plane to the defect area (median in cm) was 1200cm2/177 cm2 = 6.8 in patients without bridging, and 1750cm2/452 cm2 = 3.8 in those with bridging. The duration of surgery (median in min) was 139 and 222 min and the hospital stay was 6 and 10 days, respectively. Robotic TAR was performed predominantly for lateral and parastomal hernias. These procedures took a median of 143 and 242 min, and the hospital stay was 2 and 3 days, respectively. For robotic repair, posterior bridging was performed in 3 cases. Discussion: Using the TAR technique, even complex hernias can be safely repaired. Additional posterior bridging provides a reliable separation of the posterior plane from the intestines. Therefore, the hernia sac is always available for anterior reconstruction of the linea alba. The technique can be implemented as an open or minimally invasive procedure.

Open transversus abdominis release in incisional hernia repair: technical limits and solutions

INTRODUCTION

Incisional hernias with a defect width of more than10 cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique.

METHODS

A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions.

RESULTS

The standard PCSTAR can generally be used for a defect width of up to 15-17 cm. For defects greater than 17 cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0-97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used. For a defect width greater than 17 cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia.

Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias

PURPOSE

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias.

METHODS

Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS).

RESULTS

Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100).

CONCLUSION

ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

Transversus abdominis release (TAR) procedure: a retrospective analysis of an abdominal wall reconstruction group

Complex abdominal wall defects are important conditions with high morbidity, leading to impairment of patients' physical condition and quality of life. In the last decade, the abdominal wall reconstruction paradigm has changed due to the formation of experienced and excellence groups, improving clinical outcomes after surgery. Therefore, our study shows the perspective and outcomes of an abdominal wall reconstruction group (AWRG) in Colombia, focused on the transverse abdominis release (TAR) procedure. A retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent TAR procedures between January 2014-December 2020 were included. Analysis and description of postoperative outcomes (recurrence, surgical site infection (SSI), seroma, hematoma, and re-intervention) were performed. 47 patients underwent TAR procedure. 62% of patients were male. Mean age was 55 ± 13.4 years. Mean BMI was 27.8 ± 4.5 kg/m². Abdominal wall defects were classified with EHS ventral Hernia classification having a W3 hernia in 72% of all defects (Mean gap size of 11.49 cm ± 4.03 cm). Mean CeDAR preoperative risk score was 20.5% ± 14.5%. Preoperative use of BOTOX Therapy (OR 1.0 P 0.00 95% CI 0.3-1.1) or pneumoperitoneum (OR 0.7 P 0.04 95% CI 0.3-0.89) are slightly associated with postoperative hematoma. In terms of hernia relapse, we have 12% of cases; all of them over a year after the surgery. TAR procedure for complex abdominal wall defects under specific clinical conditions including emergency scenarios is viable. Specialized and experienced groups show better postoperative outcomes; further studies are needed to confirm our results.

Outcomes of open transverse abdominis release for ventral hernias: a systematic review, meta-analysis and meta-regression of factors affecting them

OBJECTIVES

The primary objectives were to evaluate Surgical Site Occurrences (SSO) and Surgical Site Occurrences requiring procedural Intervention (SSOPI) after open transversus abdominis release and to study various factors affecting it. Secondary objectives were to evaluate Surgical Site Infections (SSI), recurrence rates and overall complications after transversus abdominis release (TAR) and the factors responsible for those.

METHODS

We searched PUBMED, SCOPUS and Cochrane databases with keywords "transversus abdominis release" or "TAR" OR "Surgical Site Occurrences" OR "posterior component separation AND "outcomes" as per PRISMA 2020 and MOOSE guidelines. Full texts and English literature studies were included, studies mentioning outcomes for open transversus abdominis release for ventral hernia were included and studies with robotic transversus abdominis release were excluded. Percentage occurrences of SSO, SSOPI, SSI, recurrence and overall complications after TAR were evaluated. Random effect meta-analysis with restricted maximum likelihood methods was used for meta-analysis. Heterogeneity was analysed using I² statistics. Publication bias with eager's test and funnel plots. Meta0regression analysis was done to evaluate factors affecting the heterogeneity. JASP 0.16.2 software was used for meta-analysis.

RESULTS

Twenty-two studies including 5284 patients who underwent TAR for ventral hernia were included in systematic review and meta-analysis. Overall pooled SSO, SSOPI, Overall Complications, SSI and recurrence rates were 21.72% [95% C.I 17.18-26.27%], 9.82% [95% C.I 7.64 -12%], 33.34% [95% C.I. 27.43-39.26%], 9.13% [95% C.I. 6.41-11.84] and 1.6% [0.78-2.44], respectively. Heterogeneity was significant in all the analysis. Age (p < 0.001), sex (p < 0.001), BMI (p < 0.001),presence of comorbidities (p < 0.001), prior recurrence, defect size (p < 0.001) and current or past history of tobacco exposure were associated with SSO in multivariate meta-regression analysis. Defect size (p = 0.04) was associated with SSOPI. Age (p = 0.011), BMI (p = 0.013), comorbidities (p < 0.01), tobacco exposure (p = 0.018), prior recurrence (p < 0.01) and sex (p < 0.01) were associated with overall complications.

CONCLUSION

Open transversus abdominis release is associated with high rates of SSO, SSOPI, SSI and overall complications but recurrence rates are low. Various preoperative factors mentioned may be responsible for heterogeneity across studies.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review

INTRODUCTION

The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations.

METHODS

We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis.

RESULTS

Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial.

CONCLUSION

A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

Longitudinal Clinical and Patient-Reported Outcomes After Transversus Abdominis Release for Complex Hernia Repair With a Review of the Literature

PURPOSE

Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR.

METHODS

Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed.

RESULTS

Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m², respectively. The average hernia defect was 384 cm² [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05).

CONCLUSION

Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.

An evaluation of clinical and quality of life outcomes after ventral hernia repair with poly-4-hydroxybutyrate mesh

PURPOSE

Despite continued efforts, recurrence after ventral hernia repair (VHR) remains a common problem. Biosynthetic Phasix^™ (Poly-4-Hydroxybutyrate, P4HB) mesh combines the durability of synthetic mesh with the bio-resistance of biologics. P4HB has shown promising early outcomes, but long-term data are lacking. We examine patients following VHR with P4HB with at least 3 years of follow-up to assess clinical and patient reported outcomes (PROs).

METHODS

Adult patients (≥ 18 years old) undergoing VHR with P4HB mesh between 10/2015 and 01/2018 by a single surgeon were retrospectively identified. Patients with < 36 months of follow-up were excluded unless they had a documented recurrence. Clinical outcomes and quality of life using the Hernia-Related Quality of Life Survey (HerQLes) were assessed.

RESULTS

Seventy-one patients were included with a median age and body mass index of 61.2 and 31 kg/m², respectively. Mesh was placed in the retromuscular (79%) and onlay (21%) planes with 1/3 of patients having hernias repaired in contaminated fields. There were no mesh infections, enterocutaneous fistulas, or mesh explantations. Nine patients (12.7%) developed recurrence at a median follow-up of 43.1 months [38.2-49.1]. Mesh plane, fixation technique, and Ventral Hernia Working Group were not associated with recurrence. Significant improvement in disease-specific PROs was observed and maintained at 3-year follow-up.

CONCLUSION

Longitudinal clinical and quality of life outcomes after clean and contaminated VHR with P4HB are limited. Here, we conclude that P4HB is an effective and versatile mesh option for use in abdominal wall reinforcement.

Short- to Midterm Results After Posterior Component Separation with Transversus Abdominis Release: Initial Experience from India

PURPOSE

Posterior component separation with transversus abdominis release is a new procedure and is quickly gaining popularity. It has shown promising results in terms of low recurrence rates for large and complex hernias. However, there are very little Indian data available on this to date. The purpose of this study was to assess the outcomes of the technique at three centers in India.

METHODS

This was a retrospective analysis of the prospectively collected data. Patients with a minimum follow-up of 3 months who underwent open or minimal access posterior component separation were included.

RESULTS

A total of 72 patients (open = 44, minimal access = 25, and hybrid = 3) were included in the analysis. At a follow-up ranging from 3 months to 35 months, there were two recurrences (2.78%). Surgical site occurrences were seen in 23/72 (31.9%), and surgical site infection was seen in 7/72 (9.7%). Surgical site occurrence requiring procedural intervention was 3/72 (4.2%). There were two (2.78%) mortalities in the open group due to myocardial infarction.

CONCLUSION

Posterior component separation with transversus abdominis release may have advantages in terms of low recurrence in large hernias in the Indian population and can be used in carefully selected patients.

Transversus abdominis release (TAR): what are the real indications and where is the limit?

PURPOSE

To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure.

METHODS

Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center.

RESULTS

Recommendations regarding patient selection, optimization and technique for TAR are presented.

CONCLUSIONS

While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.