Open retromuscular versus laparoscopic ventral hernia repair for medium-sized defects: where is the value?

Minimally invasive intraperitoneal onlay mesh plus (IPOM +) repair versus enhanced-view totally extraperitoneal (e-TEP) repair for ventral hernias: a systematic review and meta-analysis

INTRODUCTION

Following concerns regarding an intraperitoneal mesh, newer ventral hernia repair (VHR) approaches focus on placing the mesh outside of the peritoneal cavity. The e-TEP technique used the retromuscular space and is suggested to be associated with decreased postoperative pain compared to IPOM +. This study aims to compare the IPOM + with the e-TEP for VHR.

METHODS AND PROCEDURES

We searched for studies comparing endoscopic IPOM + and e-TEP in PubMed, EMBASE, and Cochrane databases from inception until September 2023. Outcomes were Visual Analog Scale (VAS) after 24 h of surgery and between 7 and 10 days after surgery, operative time, length of stay (LOS), seroma, recurrence, and readmission. RStudio was used for statistical analysis. Heterogeneity was assessed with I2 statistics, with random effect for I2 > 25%.

RESULTS

From 149 records, 7 were included, from which 3 were RCTs, 3 were retrospective studies, and 1 was an observational prospective study. 521 patients were included (47% received e-TEP and 53% received IPOM +). 1 study included only robotic surgeries and 6 studies included only laparoscopy. Mean defect width was 3.62 cm ± 0.9 in the e-TEP group and 3.56 cm ± 0.9 in the IPOM + group. IPOM + had higher VAS after 1 day of surgery (MD - 3.35; 95% CI - 6.44; - 0.27; P = 0.033; I2 = 99%) and between 7 and 10 days after surgery (MD - 3.3; 95% CI - 5.33, - 1.28; P = 0.001; I2 = 99%). e-TEP repair showed with longer operative time (MD 52.89 min; 95% CI 29.74-76.05; P < 0.001; I2 = 92%). No differences were seen regarding LOS, seroma, recurrence, and readmission.

CONCLUSION

The e-TEP repair is associated with lower short-term postoperative pain after VHR compared to IPOM +, but with longer operative time. More RCTs are required to assess these results with long-term follow-up and determine its role in the armamentarium of the abdominal wall surgeon.

Comparative analysis of laparoscopic, retro-muscular, and open mesh repair techniques for ventral and incisional hernias: a comprehensive review and meta-analysis

Ventral hernias are abnormalities in anterior abdominal wall occurring due to an incision or are congenital. This comprehensive review and meta-analysis aim to objectively compare laparoscopic to retro-muscular or any other mesh repair approach to manage ventral incisional hernia. To identify studies that managed ventral incisional hernia using laparoscopic, open, or retro-muscular mesh repair techniques, a comprehensive literature search was performed. Random effects model was used, and data were presented as log odds ratio (logOR) or as Hedge's g with corresponding 95% confidence intervals (CI). Cochran's Q test was implemented to measure heterogeneity among articles, and funnel plots were utilized to examine publication bias visually. Quality of all selected studies was assessed using Critical Appraisal Checklists for Studies developed by the Joanna Briggs Institute. 20 studies (16,247 patients) were included published from 2003 to 2023. Significantly reduced incisional hernias developed in laparoscopic group. The recurrence of hernia lowered with laparoscopic repair vs. open repair. In retro-muscular vs. laparoscopic, recurrence was lower, however, not statistically significant (p = 0.97). Open repair type resulted in a longer hospital stay than laparoscopic (p = 0.03). In laparoscopic repair, the postoperative complications reduced compared to the open repair (p = 0.02). Laparoscopic incisional and ventral hernia repair is a practical and successful alternative to open method. It is associated with shorter hospital stay and lower risk of postoperative complications. In few instances, retro-muscular mesh repair may be opted for.

Concomitant Panniculectomy in Abdominal Wall Reconstruction: A Narrative Review Focusing on Obese Patients

The global prevalence of obesity continues to rise, contributing to an increased frequency of abdominal wall reconstruction procedures, particularly ventral hernia repairs, in individuals with elevated body mass indexes. Undertaking these operations in obese patients poses inherent challenges. This review focuses on the current literature in this area, with special attention to the impact of concomitant panniculectomy. Obese individuals undergoing abdominal wall reconstruction face elevated rates of wound healing complications and hernia recurrence. The inclusion of concurrent panniculectomy heightens the risk of surgical site occurrences but does not significantly influence hernia recurrence rates. While this combined approach can be executed in obese patients, caution is warranted, due to the higher risk of complications. Physicians should carefully balance and communicate the potential risks, especially regarding the increased likelihood of wound healing complications. Acknowledging these factors is crucial in shared decision making and ensuring optimal patient outcomes in the context of abdominal wall reconstruction and related procedures in the obese population.

Pitfalls and complications of enhanced-view totally extraperitoneal approach to abdominal wall reconstruction

BACKGROUND

The enhanced-view totally extraperitoneal access technique (eTEP) to minimally invasive retromuscular abdominal wall reconstruction is a relatively novel technique that has continued to gain popularity. There is a paucity of information regarding the prevention and management of eTEP complications. We reviewed the literature to evaluate the complications reported with eTEP ventral hernia repair and discuss the main complications associated with this technique.

METHODS

A literature search via PubMed was performed focusing on eTEP ventral hernia repair. Based on the available literature and own practice experience, the authors discuss key strategies for preventing and managing complications associated with the eTEP approach.

RESULTS

One hundred fifty studies were identified. Forty-seven studies were fully reviewed and twenty-four were included in this review. The technical details of the technique were described as performed by the authors. Postoperative complications were classified into different categories and discussed separately.

CONCLUSION

As the eTEP approach continues to gain popularity, it is essential to consider its unique complications. A focus on prevention with anatomical bearings and sound surgical technique is paramount.

Hernia Defect Closure With Barbed Suture: An Assessment of Patient-reported Outcomes in Extraperitoneal Robotic Ventral Hernia Repair

BACKGROUND

Primary closure of a fascial defect during ventral hernia repair is associated with lower rates of recurrence and better patient satisfaction compared with bridging repairs. Robotic surgery offers enhanced ability to close these defects and this has likely been aided by the use of barbed suture. The goal of this study was to evaluate the perioperative safety and the long-term outcomes for the use of barbed suture for the primary closure of hernia defects during robotic ventral hernia repair (rVHR) with mesh.

METHODS

This is a retrospective study of adult patients who underwent rVHR with the use of a barbed suture for fascial defect closure from August 2018 to August 2020 in an academic center. All the patients included were queried by phone to complete a quality of life assessment to assess patient-reported outcomes (PROs). Subjective sense of a bulge and pain at the previous hernia site has been shown to correlate with hernia recurrence. These questions were used in conjunction with a Hernia-related Quality of Life Survey (HerQles) score to assess a patient's quality of life.

RESULTS

A total of 81 patients with 102 hernias were analyzed. Sixty patients (74%) were successfully reached and completed the PRO form at median postoperative day 356 (range: 43 to 818). Eight patients (13% of patients with PRO data) claimed to have both a bulge and pain at their previous hernia site, concerning for possible recurrence. Median overall HerQLes score was 82 [Interquartile Range (IQR): 54 to 99]. Patients with a single hernia defect, when compared with those with multiple defects, had a lower rate of both a bulge (15% vs. 30%) and symptoms (33% vs. 48%), as well as a higher median HerQLes score (85 vs. 62) at the time of PRO follow-up. Patients with previous hernia repair had a lower median HerQLes score of 65 (IQR: 43 to 90) versus 88 (IQR: 62-100). These patients also had a higher rate of sensing a bulge (29% vs. 18%), whereas a sense of symptoms at the site was less (33% vs. 44%).

CONCLUSIONS

Barbed suture for fascial defect closure in rVHR was found to be safe with an acceptable rate of possible recurrence by the use of PRO data. Patients with multiple hernias and previous repairs had a higher likelihood of recurrence and a lower quality of life after rVHR.

Long-term reoperation rate following primary ventral hernia repair: a register-based study

BACKGROUND

The aim of this study was to analyse the risk for reoperation following primary ventral hernia repair.

METHODS

The study was based on umbilical hernia and epigastric hernia repairs registered in the population-based Swedish National Patient Register (NPR) 2010-2019. Reoperation was defined as repeat repair after primary repair.

RESULTS

Altogether 29,360 umbilical hernia repairs and 6514 epigastric hernia repairs were identified. There were 624 reoperations registered following primary umbilical repair and 137 following primary epigastric repairs. In multivariable Cox proportional hazard analysis, the hazard ratio (HR) for reoperation was 0.292 (95% confidence interval (CI) 0.109-0.782) after open onlay mesh repair, 0.484 (CI 0.366-0.641) after open interstitial mesh repair, 0.382 (CI 0.238-0.613) after open sublay mesh repair, 0.453 (CI 0.169-1.212) after open intraperitoneal onlay mesh repair, 1.004 (CI 0.688-1.464) after laparoscopic repair, and 0.940 (CI 0.502-1.759) after other techniques, when compared to open suture repair as reference method. Following umbilical hernia repair, the risk for reoperation was also significantly higher for patients aged < 50 years (HR 1.669, CI 1.389-2.005), for women (HR 1.401, CI 1.186-1.655), and for patients with liver cirrhosis (HR 2.544, CI 1.049-6.170). For patients undergoing epigastric hernia repair, the only significant risk factor for reoperation was age < 50 years (HR 2.046, CI 1.337-3.130).

CONCLUSIONS

All types of open mesh repair were associated with lower reoperation rates than open suture repair and laparoscopic repair. Female sex, young age and liver cirrhosis were risk factors for reoperation due to hernia recurrence, regardless of method.

Short-term outcomes of minimally invasive retromuscular ventral hernia repair using an enhanced view totally extraperitoneal (eTEP) approach: systematic review and meta-analysis

Background

The enhanced view totally extraperitoneal (eTEP) approach is becoming increasingly more widely accepted as a promising technique in the treatment of ventral hernia. However, evidence is still lacking regarding the perioperative, postoperative and long-term outcomes of this technique. The aim of this meta-analysis is to summarize the current available evidence regarding the perioperative and short-term outcomes of ventral hernia repair using eTEP.

Study design

A systematic search was performed of PubMed, EMBASE, Cochrane Library and Web of Science electronic databases to identify studies on the laparoscopic or robotic-enhanced view totally extraperitoneal (eTEP) approach for the treatment of ventral hernia. A pooled meta-analysis was performed. The primary end point was focused on short-term outcomes regarding perioperative characteristics and postoperative parameters.

Results

A total of 13 studies were identified involving 918 patients. Minimally invasive eTEP resulted in a rate of surgical site infection of 0% [95% CI 0.0–1.0%], a rate of seroma of 5% [95% CI 2.0–8.0%] and a rate of major complications (Clavien–Dindo III–IV) of 1% [95% CI 0.0–3.0%]. The rate of intraoperative complications was 2% [95% CI 0.0–4.0%] with a conversion rate of 1.0% [95% CI 0.0–3.0%]. Mean hospital length of stay was 1.77 days [95% CI 1.21–2.24]. After a median follow-up of 6.6 months (1–24), the rate of recurrence was 1% [95% CI 0.0–1.0%].

Conclusion

Minimally invasive eTEP is a safe and effective approach for ventral hernia repair, with low reported intraoperative complications and good outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02557-8.

How I Do It: Laparoscopic Ventral Hernia Repair

More than 350,000 ventral hernias are repaired annually in the United States. Currently, there is significant variation in all aspects of ventral hernia management, from preoperative patient selection to postoperative care. Herein, we detail our perioperative evaluation and management of patients selected for laparoscopic ventral hernia and our surgical technique for the performance of laparoscopic ventral hernia repair.