Outcomes of open transverse abdominis release for ventral hernias: a systematic review, meta-analysis and meta-regression of factors affecting them

Anterior component separation versus posterior component separation with transversus abdominis release for large ventral hernias: a randomized controlled study

The aim of this study was to analyze outcomes of open anterior component separation technique (ACST) and posterior component separation technique with transversus abdominis release (TAR) for midline large ventral hernias. From December 2016 to July 2022, patients over 18 years of age, who underwent elective surgery for midline large ventral hernia via open component separation technique (ACST and TAR), were enrolled in this study. Preoperative and intraoperative factors, also hospital stay days, Surgical Site Occurrences (SSO), hernia recurrence and quality of life (QoL) were determined in ACST and TAR groups. To determine QoL we used the Carolinas Comfort Scale (CCS). Data of 43 patients (22 patients from ACST group and 21-from TAR group) were analyzed. Bivariate analysis showed that the proportions of SSO in TAR group (4 out of 21; 19%) was significantly lower than in ACST group (11 out of 22; 50%) (OR 1.87, 95% CI 1.07-3.24, p = 0.033). Seroma was the most frequent SSO, ranging from 9.5% to 40.9% among the groups, respectively (P = 0.018). There was no significant difference between the groups in terms of surgical site infection (SSI), hematoma, wound dehiscence, skin necrosis, hernia recurrence and QoL. Our study revealed that when comparing the ACST and TAR groups for large midline ventral hernia, there was no significant difference in terms of hernia recurrence and QoL. TAR was associated with significantly less SSO than ACST. This can be considered as an advantage of TAR, making it more preferable than ACST.

Follow-up of complex hernia repair with intraoperative fascial traction

BACKGROUND

Different techniques for complex abdominal wall repair are utilised including intraoperative fascial traction (IFT) as the latest development. Despite increasing case numbers for IFT across Europe, long-term data especially on recurrence rates are not available yet.

METHODS

Follow-up data from five different German hernia centers between 12/2019 and 9/2023 were assessed. All patients received Rives-Stoppa repair (RSR) and IFT intraoperatively with an additional transverse abdominis muscle release (TAR) in some cases. 30-day postoperative outcome data were retrospectively collected Standardized follow-up was performed after a minimum of 3 months including clinical examination and standardized ultrasound.

RESULTS

A total of 100 patients were included in the study. The mean age was 60.7 ± 14.3 years; the mean BMI was 31.3 ± 7.3 kg/m² with a mean follow-up of 19.7 ± 10.7 months. The mean defect width was 15.8 ± 5.2 cm. In 94% of the patients complete fascial closure was achieved; in 28% an additional TAR procedure was necessary During follow-up, 2 recurrences were found. The surgical site occurrence (SSO) rate was 33% including mainly seromas (54.5%) and surgical site infections (SSI) of 9% Comparing the groups of IFT + TAR and IFT + RSR a significantly higher incidence of SSO was found in the TAR group (50% vs. 26.4%, p<0.01).

CONCLUSIONS

This study, which is the first long-term follow-up, shows very promising results of the innovative IFT technique in terms of closure rate, wound morbidity, and recurrence rate.

Comparing Open and Robotic Unilateral Transversus Abdominis Release in Incisional Hernias With a Lateral Component: A Single Center Retrospective Study

Introduction

Lateral hernias are often more challenging to correct when compared to midline defects, due to the anatomic boundaries of the bony pelvis, retroperitoneum, and costal margin. With the insurgence of robot assisted abdominal wall surgery, these defects have been found more manageable through a minimal invasive repair. In this study, we aim to present our short-term results of incisional hernia repair with a lateral component requiring a unilateral transversus abdominis release, through open surgery versus robot assisted.

Methods

A retrospective analysis was performed of our robotic and open abdominal wall repairs of lateral hernias, where a unilateral transversus abdominis release was performed, between January 2017 and December 2023. Patient, hernia and perioperative details are reported.

Results

54 patients in the open group versus 10 patients in the robotic group were included. Hernia width and hernia surface area were higher in the open group, but not significant. Operation time was similar between open and robotic procedures. In-hospital complications, surgical site infection and clinical seroma rate during the first 30 postoperative days were similar in both groups. There was a clear difference in length of stay, in favor of the robotic group.

Discussion

In our limited series, a robotic approach seems safe and feasible when faced with large lateral hernias. Short-term results show a shorter length of stay using the robotic approach, with no significant difference in short term complications, specifically SSI-rate. However, conclusions are limited due to the low number of patients and additional studies should be performed to account for long term recurrence and increase included patient number.

[Differentiated approach to surgical treatment of patients with large postoperative ventral hernia]

OBJECTIVE

To analyze the results of large postoperative ventral hernia repair using the Rives-Stoppa technique and posterior component separation between 2018 and 2023.

MATERIAL AND METHODS

We retrospectively analyzed 55 case histories of patients with large postoperative ventral hernias. The Rives-Stoppa technique was used in 25 (45.5%) patients, posterior component separation - in 30 (54.5%) patients.

RESULTS

The classical Rives-Stoppa technique was predominantly performed in women (mean age 67.3±1.2 years). In 20 (80%) patients, hernia defect did not exceed 14 cm. Mean wound drainage time was 3.8±0.7 days, mean postoperative in-hospital stay - 12.7±2.4 days. Posterior component separation was more common in men, whose age was significantly lower (58.4±2.0 years, U=160.500, p<0.001). This technique was significantly more common for hernia > 15 cm (14 (47%) patients, c²=4.288, p=0.038). Mean wound drainage time was 9.7±0.8 days, mean postoperative in-hospital stay - 18.8±1.6 days (p<0.001). In early postoperative period, 15 (27.3%) patients had wound complications. There was no significant difference in the incidence of wound complications (p=0.808), and no deaths were recorded.

CONCLUSION

A differentiated approach is necessary for large hernias. Some elderly and senile patients underwent Rives-Stoppa procedure. Posterior component separation is required for anterior abdominal wall reconstruction in young and middle-aged men. Posterior component separation significantly increases the wound drainage time and hospital-stay, but does not significantly affect the incidence of wound complications.

Outcomes after open posterior component separation via transversus abdominis release (TAR) for incisional hernia repair. A systematic review and meta-analysis

PURPOSE

Given its potential advantages, open Transversus Abdominis Release (oTAR) has been proposed as a durable solution for complex AWR. However, its applicability in different scenarios remains uncertain. We aimed to analyze the current available evidence and determine surgical outcomes after oTAR.

METHODS

We performed a systematic electronic search on oTAR in PubMed/Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Postoperative morbidity and recurrence rates were included as primary endpoints and Quality of life (QoL) was included as secondary endpoint. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) between all studies.

RESULTS

A total of 22 studies with 4,910 patients undergoing oTAR were included for analysis. Mean hernia defect and mesh area were 394 (140-622) cm2 and 1065 (557-2206) cm2, respectively. Mean follow-up was 19.7 (1-32) months. The weighted pooled proportion of recurrence, overall morbidity, surgical site occurrences (SSO), surgical site infection (SSI), surgical site occurrences requiring procedural intervention (SSOPI), major morbidity and mortality were: 6% (95% CI, 3-10%), 34% (95% CI, 26-43%), 22% (95% CI, 16-29%), 11% (95% CI, 8-16%), 4% (95% CI, 3-7%), 6% (95% CI, 4-10%) and 1% (95% CI, 1-2%), respectively. A significant improvement in QoL after oTAR was reported among studies.

CONCLUSION

Open TAR is an effective technique for complex ventral hernias as it is associated with low recurrence rate and a significant improvement in QoL. However, the relatively high morbidity rates observed emphasize the necessity of further patients' selection and optimization to improve outcomes.

Application of machine learning algorithms to predict postoperative surgical site infections and surgical site occurrences following inguinal hernia surgery

PURPOSE

This study aimed to develop, validate, and evaluate machine learning (ML) algorithms for predicting Surgical site infections (SSI) and surgical site occurrences (SSO) after elective open inguinal hernia surgery.

METHODS

A cohort of 491 patients who underwent elective open inguinal hernia surgery at Fudan University Affiliated Huadong Hospital between December 2019 and December 2020 was enrolled. To create a strong prediction model, we employed five ML methods: generalized linear model, random forest (RF), support vector machines, neural network, and gradient boosting machine. Based on the best performing model, we devised online calculators to facilitate clinicians' access to a linear predictor for patients. The receiver operating characteristic curve was utilized to evaluate the model's discriminatory capability and predictive accuracy.

RESULTS

The incidence rates of SSI and SSO were 4.68% and 13.44%, respectively. Four variables (diabetes, recurrence, antibiotic prophylaxis, and duration of surgery) were identified for SSI prediction, while four variables (diabetes, size of hernias, albumin levels, and antibiotic prophylaxis) were included for SSO prediction. In the test set, the RF model showed the best predictive ability (SSI: area under the curve (AUC) = 0.849, sensitivity = 0.769, specificity = 0.769, and accuracy = 0.769; SSO: AUC = 0.740, sensitivity = 0.513, specificity = 0.821, and accuracy = 0.667). Online calculators have been developed to assess patients' risk of SSI ( https://wuqian17.shinyapps.io/predictionSSI/ ) and SSO ( https://wuqian17.shinyapps.io/predictionSSO/ ) after surgery.

CONCLUSIONS

This study developed a prediction model for SSI/SSO using ML methods. It holds the potential to facilitate the selection of appropriate treatment options following elective open inguinal hernia surgery.

A Comparison of Open Ventral Hernia Repair Risk Stratification Systems: A Call for Consensus

Background/Objectives: Ventral hernia repair (VHR) is a common surgical intervention linked to specific surgical site complications. In such occurrences, the related morbidity is often substantial. Although known risk factors have long been recognized, their systematic inclusion in risk stratification systems lacks universal validation. This study evaluates the effectiveness and correspondence of three risk assessment tools-CeDAR, VHWG, and the modified VHWG-in predicting postoperative wound complications in VHR patients. Methods: We analyzed data from 203 patients who underwent VHR for incisional midline or lateral wall hernia across two surgical departments between 2019 and 2023. Each patient was scored using CeDAR, VHWG, and the modified VHWG systems. Outcomes were assessed based on surgical site occurrences (SSOs) such as seroma formation, wound infections, and recurrences. Results: The incidence of SSOs was 8.9%, with two recorded deaths (0.89%). CeDAR scores showed a statistically significant relationship with SSOs but failed to accurately predict complication rates across subgroups. The VHWG grading system effectively predicted higher complication rates for grades III and IV compared to grades I and II, though its modified version did not show significant predictive improvements. Secondary outcomes indicated a higher SSO rate in patients requiring posterior component separation (TAR) and those with larger hernia defects, though the differences were not statistically significant. Major preoperative risk factors, including smoking, diabetes, and obesity, did not show significant correlations with SSO rates in this study. Conclusions: Current risk estimation tools inadequately predict SSOs in VHR. Enhancing prediction accuracy will require incorporating both patient-specific and surgical factors, potentially through advanced algorithms and large-scale studies.

Short-term outcomes of minimally invasive techniques in posterior component separation for ventral hernia repair: a systematic review and meta-analysis

INTRODUCTION

The objective of this study was to perform a systematic review and meta-analysis to summarize various approaches in performing minimally invasive posterior component separation (MIS PCS) and ascertain their safety and short-term outcomes.

METHODS

A systematic literature searches of major databases were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify studies that provided perioperative characteristics and postoperative outcomes of MIS PCS. Primary outcomes for this study were: surgical site events (SSE), surgical site occurrence requiring procedural intervention (SSOPI), and overall complication rates. A random-effect meta-analysis was conducted which allows computation of 95% CIs using simple approximation and incorporates inverse variance method with logit transformation of proportions.

RESULTS

There were 14 studies that enrolled 850 participants that were included. The study identified rate of SSE, SSOPI, and overall rate of complications of all MIS TAR modifications to be 13.4%, 5.7%, and 19%, respectively.

CONCLUSIONS

Our study provides important information on safety and short-term outcomes of MIS PCS. These data can be used as reference when counseling patients, calculating sample size for prospective trials, setting up targets for prospective audit of hernia centers. Standardization of reporting of preoperative characteristics and postoperative outcomes of patients undergoing MIS PCS and strict audit of the procedure through introduction of prospective national and international registries can facilitate improvement of safety of the MIS complex abdominal wall reconstruction, and help in identifying the safest and most cost-effective modification.

Modified Chevrel Technique: A Lifesaver for Surgeons

Background and Objectives: Ventral hernias (VH) pose significant challenges for surgeons due to the risk of recurrence, complexities in aligning abdominal muscles, and selecting the most suitable layer for mesh augmentation. This study aims to evaluate the effectiveness of utilizing the anterior rectus fascia as a turnover flap in conjunction with onlay mesh reinforcement, a procedure known as the modified Chevrel technique (MCT). Materials and Methods: We conducted a retrospective analysis of patients who were operated on using MCT for abdominal hernias between January 2013 and December 2019. Data were extracted from our hospital's electronic database. Recurrence rates, as well as the rates of surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrences requiring procedural intervention (SSOPI), were analyzed based on patients' comorbidities and demographic characteristics. Results: The median follow-up period was 42.9 months (range: 14-96), and the recurrence rate was 4% (n = 3). Among the recurrent cases, three patients had chronic obstructive pulmonary disease, representing a statistically significant association (p = 0.02). Although all patients with recurrence were obese, this association did not reach statistical significance (p > 0.05). The mean hospitalization duration was 17.6 days (range: 6-29). SSO, SSI, and SSOPI rates were 39 (52%), 12 (16%), and 32 (42%), respectively. Conclusions: Managing VH remains a surgical challenge, emphasizing the importance of achieving effective abdominal closure for both functional and cosmetic outcomes. MCT presents a relatively simple approach compared to techniques like transversus abdominis release (TAR) and anterior component separation (ACS), with acceptable rates of SSO, SSOPI, SSI, and recurrence.

Outcomes of Transversus Abdominis Release With Macroporous Polypropylene Mesh

INTRODUCTION

Transversus abdominis release (TAR) is increasingly being performed for reconstruction of complex incisional and recurrent ventral hernias, with complication rates ranging from 17.4% to 33.3% after open TAR (oTAR) or robotic TAR (rTAR). The purpose of this study was to describe the outcomes of patients undergoing TAR with macroporous polypropylene mesh (MPM) and to compare outcomes between oTAR and rTAR.

METHODS

A retrospective review of 183 consecutive patients undergoing TAR with MPM performed by a single surgeon at a single institution from 2015 to 2021 was performed. Patients with less than one year of follow-up were excluded. Univariate analysis was performed to compare outcomes between oTAR and rTAR patients.

RESULTS

Average patient age was 59.4 y, median body mass index was 33.2 kg/m2, and median hernia width was 12.0 cm. Forty 2 (23%) patients underwent oTAR, 127 (69%) underwent rTAR, and 14 (8%) underwent laparoscopic TAR. Patients experienced 16.4%, 10.4%, 3.8%, and 6.0% rates of overall complications, surgical site occurrences, surgical site infections, and other complications, respectively. At average follow-up of 2.3 y, a 2.7% hernia recurrence rate was observed. In comparison to patients undergoing oTAR, rTAR patients required shorter operative times and length of stay, and were less likely to experience postoperative complications overall, and other complications. Recurrence rates were similar between oTAR and rTAR.

CONCLUSIONS

Patients undergoing TAR with MPM experienced complication and recurrence rates in alignment with previously published results. In comparison to oTAR, rTAR was associated with more favorable perioperative outcomes and complication rates, but similar recurrence rates.

Laparoscopic transversus abdominis release for complex ventral hernia repair: technique and initial findings

PURPOSE

The open Rives-Stoppa retrorectus and transversus abdominis release (TAR) techniques are well established in open ventral and incisional hernia repair. The principles are currently being translated into minimally invasive surgery with different concepts. In this study, we investigate our initial results of transperitoneal laparoscopic TAR for ventral incisional hernia repair (laparoscopic TAR).

METHODS

Over a 20-month period, 23 consecutive patients with incisional hernias underwent surgery. Laparoscopic TAR was performed transperitoneally with adhesiolysis from the anterior abdominal wall, development of the retrorectus space and TAR, midline reconstruction and extraperitoneal mesh reinforcement.

RESULTS

There were 23 incisional hernias, of which 70% were M2-M4 and 60% were W3. Median patient age was 68 years and the median BMI was 31. Median operating time was 313 min, and hospital stay was 4 days. Morbidity was 26% (Clavien-Dindo 1: n = 4 and 2 + 3b: n = 2).

CONCLUSION

With the laparoscopic TAR, it was possible to treat a series of patients with ventral incisional hernias. The operating times were long. However, with a low rate of perioperative complications the hospital stay was short As feasibility is demonstrated, the clinical relevance of the method has to be further evaluated.

Hernia Sac Preservation for Prevention of Transversus Abdominis Release in Laparoscopic Extended-Totally Extra Peritoneal Repair of Ventral Hernia: A Minimalistic Solution for a Formidable Challenge

Background: Ventral hernia repair has always been an extensive and challenging surgery. The laparoscopic extended-Totally Extraperitoneal (E-TEP) technique of ventral hernia repair is gaining popularity due to the advantage of placing a large mesh in the retro rectus plane. When done through a Laparoscopic approach, the difficulty of the procedure is compounded by multiple factors such as obtaining retro muscular access, maintaining the retro muscular plane, crossing over to the contralateral retro muscular plane without entering intraperitoneally, suturing in a limited space, and manipulation of a large mesh in a constricted space for placement. In cases of large midline incisional hernias, dense adhesions to the previous surgical scar are often present. Despite having extremely satisfying outcomes, the aforementioned factors make the laparoscopic extended-total extraperitoneal repair of large midline ventral and incisional hernias an exceptionally challenging procedure. A tension-free midline approximation is the benchmark of ventral/incisional hernia surgery. In certain cases, this can be difficult to achieve due to multiple factors. For the purpose of attaining tension-free midline closure, component separation techniques (CST) have been explored and implemented. Of these, the posterior component separation technique of Transversus Abdominis Release (TAR) has gained popularity for reducing the tension of posterior rectus sheath during posterior midline closure in retro muscular repairs by adding a few centimetres of medial advancement. The main pitfall of TAR is its technical complexity, which may result in morbid complications when implemented incorrectly. Performing TAR laparoscopically compounds the complexity manyfold. Hence, to obviate the necessity to perform Laparoscopic TAR in cases of Laparoscopic E-TEP repair of large midline ventral and incisional hernias, we present that the technique of hernial sac preservation should be pre-emptively carried for all Laparoscopic ETEP repairs so that the necessity of performing TAR in select cases is reduced by aiding in the addition of final crucial centimetres of lengthening to the posterior rectus sheath for achieving posterior midline closure. This aids in the success of the procedure by preventing an additional complex procedure of TAR from being performed in an already challenging hernia repair technique of Laparoscopic E-TEP repair. Methods: We hereby report three cases of Ventral hernia repair in which Laparoscopic E-TEP repair was carried out and Hernial sac preservation technique was implemented successfully. Midline closure of the posterior rectus sheath was attained under reduced tension and a medium-weight macroporous polypropylene mesh was placed in the retro-rectus plane after measurement of the potential space. Patients were discharged uneventfully. Results: Patients were followed up for up to 6 months postoperatively and were found to have no complications. Conclusion: In Laparoscopic E-TEP repair of midline ventral hernias, preservation of the hernial sac along with the posterior rectus sheath might aid in the prevention of performing a TAR in selected cases where posterior layer tension is present. Hernia sac preservation thereby aids in reducing operative time and preventing potential morbid complications.