Is there an advantage to laparoscopy over open repair of primary umbilical hernias in obese patients? An analysis of the Americas Hernia Society Quality Collaborative (AHSQC)

Obesity increases the surgical complexity and risk of recurrence after midline primary ventral hernia repair: results on 2307 patients from the French Society of hernia surgery (SFCP-CH) registry database

PURPOSE

Obesity is a known risk factor of recurrence after hernia surgery, but available data often concern pooled cases of primary and incisional hernia, with short follow-up. We aimed to analyze the impact of severe obesity (BMI ≥ 35 kg/m2) on the results of midline primary ventral hernia repair (mPVHR), in comparison with non-severely obese patients.

METHODS

Data were extracted from a multicentric registry, in which patients' data are consecutively and anonymously collected. We conducted a retrospective comparative study on patients with severe obesity (sOb) versus non-severely obese patients (non-sOb), who underwent surgery, with a minimal 2-year follow-up after their mPVHR.

RESULTS

Among 2307 patients, 267 sOb and 2040 non-sOb matched inclusion criteria. Compared with non-sOb, sOb group gathered all the worse conditions and risk factors: more ASA3-4 (39.3% vs. 10.2%; p < 0.001), symptomatic hernia (15.7% vs. 6.8%; p < 0.001), defect > 4 cm in diameter (24.3% vs. 8.8%; p < 0.001), emergency surgery (6.1% vs. 2.5%; p = 0.003), and Altemeir class > 1 (9.4% vs. 2.9%; p < 0.001). Laparoscopic IPOM was used more often in sOb patients (40% vs. 32%; p = 0.016), but with smaller Hauters' ratio (46 vs. 73; p < 0.001). Compared with the non-sOb, the rate of day-case surgery was lower (48% vs. 68%; p < 0.001), the surgical site occurrences were significantly more frequent (6.4 %vs. 2.5%; p < 0.001). The main outcome, 2-year recurrence, was 5.9% in the sOb vs. 2.1% (p = 0.008), and 2-year reoperations was 3% vs. 0.3% (p = 0.006). In the adjusted analysis, severe obesity was an independent risk factor for recurrence [OR = 2.82, (95%CI, 1.45; 5.22); p = 0.003].

CONCLUSION

In patients with severe obesity, mPVHR is technically challenging and recurrence rate is three times higher than that of non-severely obese patients.

Incidence of wound dehiscence in patients undergoing laparoscopy or laparotomy: a systematic review and meta-analysis

Surgical wound dehiscence (SWD) is a serious complication-with a 40% estimated mortality rate-that occurs after surgical intervention. Since the implementation of advanced recovery protocols, the current global incidence of SWD is unknown. This systematic review and meta-analysis estimated the worldwide incidence of SWD and explored its associated factors in general surgical patients. Eligible full-text cross-sectional, cohort and observational studies in English, between 1 January 2010 to 23 April 2021, were retrieved from MEDLINE, CINAHL, EMBASE and the Cochrane Library. Data extraction and quality appraisal were undertaken independently by three reviewers. Random effects meta-analytic models were used in the presence of substantial inconsistency. Subgroup, meta-regression and sensitivity analyses were used to explore inconsistency. Publication bias was assessed using Hunter's plots and Egger's regression test. Of 2862 publications retrieved, 27 studies were included in the final analyses. Pooled data from 741,118 patients across 24 studies were meta-analysed. The 30-day cumulative incidence of SWD was 1% (95% Confidence Interval (CI): 1-1%). SWD incidence was highest in hepatobiliary surgery, at 3% (95% CI: 0-8%). Multivariable meta-regression showed SWD was significantly associated with duration of operation and reoperation (F=7.93 (2-10); p=0.009), explaining 58.2% of the variance. Most studies were retrospective, predated the agreed global definition for SWD and measured as a secondary outcome; thus, our results likely underestimate the scope of the problem. Wider uptake of the global definition will inform the SWD surveillance and improve the accuracy of reporting.

[Treatment of ventral hernias in patients with morbid obesity]

The review is devoted to the treatment of ventral hernias in patients with morbid obesity. This issue is important due to significant number of such patients and no unambiguous clinical recommendations. The advantages of simultaneous surgery (with bariatric intervention) are obvious, i.e. lower risk of postoperative hernia incarceration and no need for re-hospitalization with another intervention. High risk of bariatric population makes it necessary to minimize surgery time and surgical trauma. A staged approach with reducing body weight surgically or conservatively before hernia repair is often chosen. Hernia repair should be performed using laparoscopic or robotic techniques with obligatory use of mesh implants. Panniculectomy or abdominoplasty as the main surgery is a valid option. Currently, it is necessary to develop clear criteria for selecting patients with morbid obesity for staged and simultaneous treatment of ventral hernias.

Three-Year Clinical Outcomes and Quality of Life after Retromuscular Resorbable Mesh Repair Using Fibrin Glue

BACKGROUND

With 400,000 hernias repaired annually, there is a need for development of efficient and effective repair techniques. Previously, the authors' group compared perioperative outcomes and hospital costs of patients undergoing ventral hernia repair with retromuscular mesh using suture fixation versus fibrin glue. This article reports on 3-year postoperative outcomes, including hernia recurrence, long-term clinical outcomes, and patient-reported quality of life.

METHODS

Patients who underwent ventral hernia repair performed by a single surgeon between 2015 to 2017 were identified. Patients with retromuscular resorbable mesh placed were included and matched by propensity score. Primary outcomes included hernia recurrence, surgical-site infection, surgical-site occurrence, and surgical-site occurrence/surgical-site infection requiring procedural interventions. Secondary outcomes included quality of life as assessed by the Hernia-Related Quality of Life Survey.

RESULTS

Sixty-three patients were eligible, and 46 patients were matched (23 suture fixation and 23 fibrin glue), with a median age of 62 years, a median body mass index of 29 kg/m2, and a median defect size of 300 cm2 (interquartile range, 180 to 378 cm2). Median follow-up was 36 months (interquartile range, 31 to 36 months). There was no difference in the incidence of hernia recurrence (13.0 percent for suture fixation and 8.7 percent for fibrin glue; p = 0.636) or other postoperative outcomes between techniques (all p > 0.05). Five patients required reoperation because of a complication (10.9 percent). Overall quality of life improved preoperatively to postoperatively at all time points (all p < 0.05), and no differences in quality-of-life improvement were seen between techniques (p > 0.05).

CONCLUSION

Ventral hernia repair with atraumatic resorbable retromuscular mesh fixation using fibrin glue demonstrates equivalent postoperative clinical and quality-of-life outcomes when compared to mechanical suture fixation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Are perioperative outcomes in cancer-related ventral incisional hernia repair worse than in the general population? An Abdominal Core Health Quality Collaborative (ACHQC) database study

PURPOSE

Patients with a history of cancer-related abdominal surgery undergoing incisional hernia repair (IHR) are highly heterogenous and increasingly prevalent. We explored whether cancer surgery should be considered an independent risk factor for worse IHR perioperative outcomes.

METHODS

Patients undergoing IHR between 2018 and 2020 were identified within the Abdominal Core Health Quality Collaborative (ACHQC). Regression models were used to assess associations between cancer operation history and 30 d surgical site occurrences-exclusive of infection (SSO-EIs), surgical site infections (SSIs), reoperations, time to recurrence, and quality of life (QoL) scores. Cancer cohort subgroup analysis was performed for operative approach and mesh location.

RESULTS

8019 patients who underwent IHR were identified in the ACHQC, 1321 of which had a history of cancer operation. Cancer cohort patients were more likely to be older, males with a higher ASA status and lower BMI, and have longer and wider hernias (p < 0.001). After adjusting for confounding, the cancer cohort was less likely to experience SSO-EIs (OR 0.74, 95% CI 0.59-0.94 p = 0.0092) and showed lower odds of SSIs, reoperations, and recurrence (SSI OR 0.7, 95% CI 0.47-1.05, p = 0.0542; reoperation OR 0.66, 95% CI 0.37-1.17, p = 0.1002; recurrence OR 0.8, 95% CI 0.63-1.02, p = 0.08). There was no difference in postoperative QoL scores between cohorts. There were also no differences in perioperative or QoL outcomes within the cancer cohort based on operative approach or mesh location.

CONCLUSION

These data show no evidence that history of cancer operation predisposes patients to worse incisional hernia repair perioperative or quality of life outcomes.

Subxiphoid top-down endoscopic totally preperitoneal approach (eTPA) for midline ventral hernia repair

PURPOSE

Midline abdominal wall hernia repair is among the most common surgical interventions performed worldwide. However, the optimal surgical technique remains controversial. To overcome the disadvantages of both open and transabdominal procedures, we developed a totally endoscopic preperitoneal approach (eTPA) with placement of a large mesh.

METHODS

From December 2019 to October 2020, 20 consecutive patients with small to medium-sized midline ventral hernias underwent repair using a completely preperitoneal subxiphoid top-down approach. The preperitoneal space was entered directly below the xiphoid, and careful endoscopic development of the plane between the peritoneum and posterior sheath of the rectus fascia was then performed behind the linea alba. The hernia sac and its contents were identified and reduced. The hernia defect was closed with sutures, and a mesh with an adequate high defect: mesh ratio was placed in the newly created preperitoneal space.

RESULTS

Twenty patients were enrolled in this study, including 14 with primary umbilical hernias, 4 with primary epigastric hernias, and 2 with recurrent umbilical hernias. 15 patients suffered from a mild concomitant diastasis recti. All operations were successfully completed without conversion to open repair. The mean operative time was 105.3 min (range, 60-220 min). Postoperative pain was mild, and the mean visual analog scale score for pain was 1.8 on the first postoperative day. The average postoperative hospital stay was 1.8 days (range, 1-4 days). One patient developed a minor postoperative seroma, but it had no adverse impact on the final outcome. No patients developed recurrence during the 3- to 10-month follow-up period.

CONCLUSIONS

The subxiphoid top-down totally endoscopic preperitoneal approach (eTPA) technique is feasible and effective. It may become a valuable alternative for the treatment of primary small- (defect size < 2 cm) and medium-sized (2-4 cm) midline ventral hernias, particularly in presence of a concomitant diastasis recti.

Assessment of potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair: a registry-based multivariable analysis of 31,965 patients

INTRODUCTION

How best to treat a small (< 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors.

METHODS

The data of patients with primary elective umbilical hernia repair and defect size < 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up.

RESULTS

31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates.

CONCLUSION

Suture repair continues to be used for 78% of umbilical hernias with a defect < 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).