Management of epigastric, umbilical, spigelian and small incisional hernia as a day case procedure: results of long-term follow-up after open preperitoneal flat mesh technique

The feasibility and safety of ventral hernia repairs under local anaesthesia: a systematic review

BACKGROUND

Ventral hernias represent a significant global healthcare burden. Repair under local anaesthesia (LA) provides benefits to patients, hospitals and economies. While inguinal hernia repair under LA has been established, this has not translated to other abdominal wall hernias. This systematic review evaluates the feasibility, safety, and efficacy of performing these repairs under LA.

METHODS

A systematic review was conducted using OVID® EMBASE and MEDLINE to review articles published between 1966 and 2023. Thirty-three papers were included examining variables such as type of hernia, complications, cost-effectiveness, LA used and length of stay. All papers were quality assessed using the ROBINS-I tool. Papers assessing inguinal hernias were excluded.

RESULTS

13,491 patients underwent ventral hernia repair under LA. Complication rates for LA repairs are low, with wound infections and hematomas ranging from 0.3 to 2%. Recurrence rates were also low (0.3-2.5%). Early mobilisation and same-day discharge were notable benefits, with over 97% of patients ambulatory within hours. Postoperative pain was minimal, contributing to high patient satisfaction rates (90-97%). LA repairs proved especially beneficial for high-risk groups, including elderly and frail patients. However, these findings were only seen in hernia defects less than 5 cm. Heterogeneity among study populations, small sample sizes, and lack of standardisation in LA administration were noted.

CONCLUSION

This review supports the broader implementation of LA for ventral hernia repairs in small defects (< 5 cm), demonstrating its safety, feasibility, and patient acceptability. Careful patient selection for standardisation of best practices for LA hernia repairs offers the potential for significant cost-savings with overall favourable outcomes.

Day Surgery for Spigelian Hernia Repair Under Local Anesthesia: A “Real Minimally Invasive” Surgical Approach

Spigelian hernia (SH) represents less than 1% of all hernias and about 0,1% of abdominal wall hernias. Although it is a very rare hernia, it has a considerably high risk of strangulation. The aim of this work is to propose the open approach based on local anesthesia on a Day Surgery regimen as a safe treatment for Spigelian Hernia surgery. We report a series of 17 clinical cases (9 men and 8 women, between 40 and 80 years old) who underwent SH open repair on a Day Surgery basis between 2004 and 2021 in our University Hospital. In our single-center case series, no early postoperative complications occurred, except for a bulky seroma of about 800 cc. No prosthesis or surgical wound infections occurred and no recurrences were observed in the early postoperative period. Looking at our experience and the literature, Spigelian hernia repair under local anesthesia on a Day Surgery regimen, using a pre-peritoneal polypropylene mesh, could be proposed as a safe and “real minimally invasive” approach in elective settings.

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors

PURPOSE OF REVIEW

Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases).

RECENT FINDINGS

Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated.

SUMMARY

This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

Umbilical hernia: could it be the 'canary in the coal mine' for a more significant abdominal wall problem?

BACKGROUND

A considerable proportion of incisional hernias presenting to this unit evolve following simple umbilical hernia repair. Our aim was to review our series of complex ventral hernia repairs and identify the frequency of this problem. Our secondary aim was to encourage surgeons to evaluate whether any of the factors that increase the risk of recurrent hernia may be present, prior to undertaking an umbilical hernia repair.

METHODS

Observational retrospective review of a prospectively maintained single-surgeon database of consecutive patients undergoing surgery for recurrent ventral hernia. Patients presenting with recurrence at the site of a previous umbilical hernia repair were identified and their demographic data collected and analysed. A review of the published literature was performed. Patient and surgeon factors contributing to recurrence were identified and discussed.

RESULTS

Of 386 patients undergoing surgery for a recurrent ventral hernial, 102 (26.4%) were initially managed as 'simple' umbilical hernias repaired with a mesh patch or primary suture repair. 71 (69.6%) patients had undergone one or more subsequent hernia repairs prior to referral to our unit with 16 (15.6%) having had three or more repairs prior to referral.

CONCLUSION

Recurrence rates after umbilical hernia repair are likely to be much higher than surgeons and patients appreciate. There are many aspects to consider in the repair of a 'simple' umbilical hernia and we seek promote a discussion amongst surgeons that umbilical hernias be assessed as a major abdominal wall condition and not relegated to minor surgery status.

Persistent low rates of same-day umbilical hernia repair in Australia over the past 20 years: is there a need to change?

BACKGROUND

Several recent reports have identified significant variations in discharge practices following umbilical hernia repair (UHR). The primary aim of this paper is to determine Australian UHR same day discharge (SDD) rates over the past two decades. Secondary aims are to analyse factors which may contribute to variation in discharge practices, compare Australian UHR SDD rates internationally and determine LOS trends.

METHODS

A retrospective, population-based cohort study was conducted using de-identified data from the Australian Institute of Health and Welfare (1 July 1998 to 30 June 2019). SDD rates and LOS were calculated for age, gender and complexity. Negative binomial models were used to investigate associations between characteristics.

RESULTS

The overall mean UHR SDD rate was 41.2% with a modest improvement over the study period (36.5% to 44.4%, P < 0.0001). The mean LOS was 3.4 days, and this decreased over the study period (P = 0.01). Males had a higher rate of SDD (42.1% vs. 39.4%, P < 0.0001) and shorter LOS (3.0 vs. 3.7 days, P < 0.0001) compared with females. Increased age was associated with decreased SDD (P < 0.0001) and increased LOS (P < 0.0001). Australia's SDD rate was lower than in both New Zealand and the United Kingdom.

CONCLUSION

While SDD and LOS following UHR improved across the study period, SDD rates remain below the RACS recommendation and compare unfavourably internationally. Advancing age and female gender were associated with decreased SDD and increased LOS demonstrating potential areas for improvement. Multiple strategies are discussed to address the persistently low rates of SDD after UHR.