Abdominal wall hernia surgery in The Netherlands: a national survey

BMI: does it predict the need for component separation?

PURPOSE

Patient optimization and selecting the proper technique to repair large incisional hernias is a multifaceted challenge. Body mass index (BMI) is a modifiable variable that may infer higher intra-abdominal pressures and, thus, predict the need for component separation (CS) at the time of surgery, but no data exist to support this. This paper assesses if the ratio of anterior-posterior (AP): transverse (TRSV) abdominal diameter, from pre-operative CT imaging, indicates a larger proportion of intra-abdominal fat and correlates with a hernia defect requiring a component separation for successful tension-free closure.

METHODS

Ninety patients were identified who underwent either an open hernia repair with mesh by primary closure (N = 53) or who required a component separation at the time of surgery (N = 37). Pre-operative CT images were used to measure hernia defect width, AP abdominal diameter, and TRSV abdominal diameter. Quantitative data, nominal data, and logistic regression was used to determine predictors associated with surgical group categorization.

RESULTS

The average hernia defect widths for primary closure and CS were 7.7 ± 3.6 cm (mean ± SD) and 9.8 ± 4.5, respectively (p = 0.015). The average BMI for primary closure was 33.9 ± 7.2 and 33.8 ± 4.9 for those requiring CS (p = 0.924). The AP:TRSV diameter ratios for primary closure and CS were 0.41 ± 0.08 and 0.49 ± 0.10, respectively (p < 0.001). In a multivariate analysis including both defect width and AP:TRSV diameter ratio, only AP:TRSV diameter ratio predicted the need for a CS (p = 0.001) while BMI did not (p = 0.92).

CONCLUSION

Intraabdominal fat distribution measured by AP:TRSV abdominal diameter ratio correlates with successful tension-free fascial closure during incisional hernia repair, while BMI does not.

Prehabilitation of complex ventral hernia patients with Botulinum: a systematic review of the quantifiable effects of Botulinum

PURPOSE

Complex ventral hernia repair (CVHR) encompasses patient optimization, primary fascial closure (PFC), mesh reinforcement and component separation technique (CST), if needed. High rates of complications after CST are still reported. Prehabilitation by managing pre-operative modifiable risk factors, like abdominal wall compliance, possibly reduces these rates. Compliance can be modified by intramuscular injection of Botulinum in the lateral abdominal wall muscles (LAWM). Paralysis leads to elongation of these muscles, which may facilitate PFC and/or prevent CST. Evidence to use Botulinum in hernia patients is scarce and fragmented. An update of evidence for the effect of Botulinum is presented.

METHODS

A multi-database search was conducted for Botulinum studies in ventral hernia patients. A systematic review was performed to describe its primary effect on compliance (LAWM elongation) and secondary effects like PFC ± CST rate, complications and recurrence.

RESULTS

14 studies were included (377 patients) with a HDW of median 12 (10-15) cm. A typical intervention consisted of 200-300 U Botulinum in 3 points per hemi-abdomen under US guidance, > 2 weeks pre-operatively and evaluated by CT just before the operation. The primary effect was a median LAWM elongation of 4.0 cm per side without complications of the injection (four studies, 107 patients). The median PFC rate was 100%, CST rate 38%, wound-related complications 19%, medical complications 18% and recurrence 0% (14 studies).

CONCLUSION

Botulinum safely elongates the abdominal wall muscles, but the level of evidence available remains low. Any patient in whom PFC is expected to be difficult, could be a candidate for prehabilitation with Botulinum.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.