The use of biosynthetic mesh in giant hiatal hernia repair: is there a rationale? A 3-year single-center experience

The Madrid Posterior Component Separation: An Anatomical Approach for Effective Reconstruction of Complex Midline Hernias

Introduction

In recent years, Posterior Component Separation (PCS) with the Madrid modification (Madrid PCS) has emerged as a surgical technique. This modification is believed to enhance the dissection of anatomical structures, offering several advantages. The study aims to present a detailed description of this surgical technique and to analyse the outcomes in a large cohort of patients.

Materials and Methods

This study included all patients who underwent the repair of midline incisional hernias, with or without other abdominal wall defects. Data from patients at three different centres specialising in abdominal wall reconstruction was analysed. All patients underwent the Madrid PCS, and several variables, such as demographics, perioperative details, postoperative complications, and recurrences, were assessed.

Results

Between January 2015 and June 2023, a total of 223 patients underwent the Madrid PCS. The mean age was 63.4 years, with a mean BMI of 33.3 kg/m2 (range 23-40). According to the EHS classification, 139 patients had a midline incisional hernia, and 84 had a midline incisional hernia with a concomitant lateral incisional hernia. According to the Ventral Hernia Working Group (VHWG) classification, 177 (79.4%) patients had grade 2 and 3 hernias. In total, 201 patients (90.1%) were ASA II and III. The Carolinas Equation for Determining Associated Risks (CeDAR) was calculated preoperatively, resulting in 150 (67.3%) patients with a score between 30% and 60%. A total of 105 patients (48.4%) had previously undergone abdominal wall repair surgery. There were 93 (41.7%) surgical site occurrences (SSO), 36 (16.1%) surgical site infections (SSI), including 23 (10.3%) superficial and 7 (3.1%) deep infections, and 6 (2.7%) organ/space infections. Four (1.9%) recurrences were assessed by CT scan with an average follow-up of 23.9 months (range 6-74).

Conclusion

The Madrid PCS appears to be safe and effective, yielding excellent long-term results despite the complexity of abdominal wall defects. A profound understanding of the anatomy is crucial for optimal outcomes. The Madrid modification contributes to facilitating a complete retromuscular preperitoneal repair without incision of the transversus abdominis. The extensive abdominal wall retromuscular dissection obtained enables the placement of very large meshes with minimal fixation.

Hiatal hernia repair with biosynthetic mesh reinforcement: a qualitative systematic review

INTRODUCTION

Reinforcement of crural closure with synthetic resorbable mesh has been proposed to decrease recurrence rates after hiatal hernia repair, but continues to be controversial. This systematic review aims to evaluate the safety, efficacy, and intermediate-term results of using biosynthetic mesh to augment the hiatus.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed throughout this systematic review. The Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias in Randomized Trials tools were used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study design, risk of bias, publication bias, and statistical analysis.

RESULTS

The systematic literature search found 520 articles, 101 of which were duplicates and 355 articles were determined to be unrelated to our study and excluded. The full text of the remaining 64 articles was thoroughly assessed. A total of 18 articles (1846 patients) were ultimately included for this review, describing hiatal hernia repair using three different biosynthetic meshes-BIO-A, Phasix ST, and polyglactin mesh. Mean operative time varied from 127 to 223 min. Mean follow up varied from 12 to 54 months. There were no mesh erosions or explants. One mesh-related complication of stenosis requiring reoperation was reported with BIO-A. Studies showed significant improvement in symptom and quality-of-life scores, as well as satisfaction with surgery. Recurrence was reported as radiologic or clinical recurrence. Overall, recurrence rate varied from 0.9 to 25%.

CONCLUSION

The use of biosynthetic mesh is safe and effective for hiatal hernia repair with low complications rates and high symptom resolution. The reported recurrence rates are highly variable due to significant heterogeneity in defining and evaluating recurrences. Further randomized controlled trials with larger samples and long-term follow-up should be performed to better analyze outcomes and recurrence rates.

Minimally Invasive Abdominal Repair of a Giant Paraesophageal Hiatal Hernia with Occupation of the Right Thorax in a 53-Year-Old Man

Paraesophageal giant hiatal hernia is a rare condition associated with serious complications if not treated surgically. There are no reports of the minimally invasive abdominal repair of a giant hiatal hernia of the stomach almost entirely occupying the right thoracic cavity. The most common clinical presentation includes pathological gastroesophageal reflux, dysphagia, chest pain, or respiratory symptoms such as chronic cough or dyspnoea. Chest computed tomography, upper gastrointestinal endoscopy, and high-resolution oesophageal manometry are used to indicate the best treatment. This article reports the minimally invasive abdominal repair of a case of paraesophageal giant hiatal hernia occupying the right thoracic cavity.

Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See?

Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.