Impact of obesity on postoperative complications after laparoscopic and open incisional hernia repair – A prospective cohort study

Comparison of short-term outcomes following robotic ventral hernia repair in patients with obesity: a review of 9742 patients from the Abdominal Core Health Quality Collaborative database

Despite the paucity of evidence on robotic ventral hernia repair (RVHR) in patients with obesity, the robotic platform is being used more frequently in hernia surgery. The impact of obesity on RVHR outcomes has not been thoroughly studied. Obesity is considered a major risk factor for the development of recurrent ventral hernias and postoperative complications; however, we hypothesize that patients undergoing robotic repairs will have similar complication profiles despite their body mass index (BMI). We performed a retrospective analysis of patients aged 18-90 years who underwent RVHR between 2013 and 2023 using data from the Abdominal Core Health Quality Collaborative registry. Preoperative, intraoperative, and postoperative characteristics were compared in non-obese and obese groups, determined using a univariate and logistic regression analysis to compare short-term outcomes. The registry identified 9742 patients; 3666 were non-obese; 6076 were classified as obese (BMI > 30 kg/m2). There was an increased odds of surgical site occurrence in patients with obesity, mostly seroma formation; however, obesity was not a significant factor for a complication requiring a procedural intervention after RVHR. In contrast, the hernia-specific quality-of-life scores significantly improved following surgery for all patients, with those with obesity having more substantial improvement from baseline. Obesity does increase the risk of certain complications following RVHR in a BMI-dependent fashion; however, the odds of requiring a procedural intervention are not significantly increased by BMI. Patients with obesity have a significant improvement in their quality of life, and RVHR should be carefully considered in this population.

Evaluating postoperative hernia incidence and risk factors following pelvic exenteration

Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre.

METHOD

A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination.

RESULTS

A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative.

CONCLUSION

This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.

T-line Hernia Mesh Repairs of Large Umbilical Hernias: Technique and Short-term Outcomes

Background

The T-line hernia mesh is a synthetic, polypropylene mesh specifically designed to prevent anchor point failure by evenly distributing tension through mesh suture extensions. This case series illustrates the first clinical application of the T-line mesh for umbilical hernia repair (UHR).

Methods

This study is a retrospective, consecutive cases series of all adult patients presenting to a single surgeon with symptomatic umbilical hernia requiring surgical repair using the T-line hernia mesh. Patient demographics, surgical details, and 30-day postoperative complications were collected. Descriptive statistics were computed in Microsoft Excel (Redmond, Va.).

Results

Three patients presented for UHR. All three patients were obese with mean body mass index of 37.5 ± 6.6. Two patients were former smokers, and two had presented after hernia recurrence. The average defect size was 80.1 cm2 ± 94.0 cm2. Two patients had UHR with onlay mesh placement, whereas one had a transversus abdominus release followed by retrorectus mesh placement. The average mesh size was 192.3 cm2 ± 82.5 cm2. All three cases were classified as clean. There were no intraoperative complications. No patients experienced 30-day postoperative complications or recurrence.

Conclusions

We present a case series of three patients presenting with large, symptomatic umbilical hernias who underwent UHR with T-line hernia mesh reinforcement without short term complications or hernia recurrence at last follow-up.

Laparoscopic treatment of ventral hernias: the Italian national guidelines

Primary and incisional ventral hernias are significant public health issues for their prevalence, variability of professional practices, and high costs associated with the treatment In 2019, the Board of Directors of the Italian Society for Endoscopic Surgery (SICE) promoted the development of new guidelines on the laparoscopic treatment of ventral hernias, according to the new national regulation. In 2022, the guideline was accepted by the government agency, and it was published, in Italian, on the SNLG website. Here, we report the adopted methodology and the guideline's recommendations, as established in its diffusion policy. This guideline is produced according to the methodology indicated by the SNGL and applying the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Fifteen recommendations were produced as a result of 4 PICO questions. The level of recommendation was conditional for 12 of them and conditional to moderate for one. This guideline's strengths include relying on an extensive systematic review of the literature and applying a rigorous GRADE method. It also has several limitations. The literature on the topic is continuously and rapidly evolving; our results are based on findings that need constant re-appraisal. It is focused only on minimally invasive techniques and cannot consider broader issues (e.g., diagnostics, indication for surgery, pre-habilitation).

Ring closure outcome for laparoscopic ventral hernia repair (IPOM plus) in medium and large defects. Long-term follow-up

BACKGROUND

Despite advances in laparoscopic ventral hernia repair (LVHR) with the Intra-peritoneal onlay mesh technique (IPOM), recurrence continues to be a frequent postoperative complication. The aim of this study is to analyze the long-term recurrence rate in two series, by incorporating in IPOM technique the laparoscopic closure of the defect (IPOM plus). We also want to determine the ring size cut-off point from which the recurrence risk increases in IPOM technique and determine if the cut-off point is modified with IPOM plus technique.

METHODS

A comparative retrospective study was conducted analyzing patients who underwent LVHR. They were divided into 2 groups according to the surgical technique used: IPOM or IPOM plus. We determined in each group the cut-off point where the ring size presents a greater recurrence risk by calculating the better point of sensitivity/specificity relationship of the ROC curve.

RESULTS

Between 2007 and 2018, 286 patients underwent LVHR. The ROC curve for IPOM technique has shown a cut-off point of higher recurrence risk for rings larger than 63 cm2. While the ROC curve in IPOM plus group showed an increase in the cut-off point, with a higher recurrence risk in rings > 168 cm2. Overall median ring size was 30 cm2 (range 4-225; IQR 16-61). However, when comparing the ring size between techniques we found a relatively larger size in IPOM plus (p: 0.013). The recurrence rate in the IPOM group was 19.51% while in the IPOM plus group was 3.57% (p: 0.005).

CONCLUSIONS

For standard LVHR with IPOM technique, the greatest recurrence risk occurs in rings larger than 63 cm2. The addition of ring closure (IPOM plus) was associated with a recurrence risk reduction, which occurs in rings larger than 168 cm2. These findings would allow expanding the indication for LVHR, using the IPOM plus technique.

Minimally invasive versus open living donors right hepatectomy: A systematic review and meta-analysis

BACKGROUND

Although minimally invasive technology has been widely used in hepatectomy, it remains controversial with regards to liver transplantation, especially in donors right hepatectomy. Herein, we compared the short-term safety and efficacy of minimally invasive donors right hepatectomy (MIDRH) with open donors right hepatectomy (ODRH).

METHODS

A systematic literature search was carried out using PubMed, Embase, Web of Science and the Cochrane Library database in order to identify comparison studies of MIDRH and ODRH. Next, we obtained the relevant data, and carried out the meta-analysis.

RESULTS

This meta-analysis included 12 studies, which included 1755 cases that underwent donors right hepatectomy. Compared to ODRH, patients that underwent MIDRH had less bleeding (SWD = -0.52, p<0.001), shorter hospital stays (SWD = -0.58, p < 0.001) and lower overall postoperative complications of donors (RR = 0.74, p = 0.008). However, MIDRH was found to be associated with prolonged operative times (SWD = 0.74, p < 0.001), as well as a higher rate of biliary complications in donors (RR = 2.26, p = 0.007) and recipients (RR = 1.69, p < 0.001). There were no statistically significant differences between MIDRH and ODRH in postoperative liver function, rate of major complications and vascular complications of both donors and recipients and overall postoperative complications.

DISCUSSION

MIDRH is superior to ODRH with regards to intraoperative bleeding, postoperative hospital stay and overall donor complications. Although biliary-related complications are higher, it is feasible to develop MIDRH in experienced liver transplant centers. However, higher-quality research is still needed for corroboration.

Laparoscopic ventral hernia repair: does IPOM plus allow to increase the indications in larger defects?

PURPOSE

The laparoscopic ventral hernia repair (LVHR) may have a limit of effectiveness, especially in defects greater than 80 cm², with a higher recurrence rate which contraindicates this technique. The purpose of this study is to analyze the indication of LVHR determining and comparing the recurrence rate according to defect size in two series.

METHODS

We analyzed all patients who underwent LVHR between 2007 and 2017. Patients were divided according to the ring size: < o ≥ 80 cm² into group one (G1) and group two (G2) respectively. In both groups, all three techniques were used: intraperitoneal onlay mesh (IPOM), IPOM with closure of the defect (IPOM plus), and IPOM plus + anterior videoscopic component separation (AVCS).

RESULTS

A total of 258 patients underwent LVHR. Mean recurrence rate was 13% in G1 and 24% in G2. A statistically significant difference was found when comparing the IPOM technique among both groups, with a higher recurrence rate when ring size was ≥ 80 cm² (p < 0.5). However, when comparing recurrence rate in IPOM plus and IPOM plus + AVCS between both groups, no significant differences were observed, yielding a p of 0.51 and 0.63, respectively.

CONCLUSION

The IPOM technique has shown a limit of effectiveness in large ventral hernia defects. The combination of techniques (ring closure and AVCS) may be useful to expand the indication for this surgery to larger defects and to reduce the recurrence rate. Prospective randomized studies are required to confirm this trend.

Prophylactic Onlay Mesh Repair (POMR) Versus Primary Suture Repair (PSR) for Prevention of Incisional Hernia (IH) After Abdominal Wall Surgery: A Systematic Review and Meta-analysis

BACKGROUND

With many different operative techniques in use to reduce the incidence of incisional hernias (IH) following a midline laparotomy, there is no consensus among the clinicians on the efficacy and safety of any particular repair technique. This meta-analysis compares the prophylactic onlay mesh repair (POMR) and primary suture repair (PSR) for the incidence of IH.

METHODS

A meta-analysis and systematic review of MEDLINE, PubMed Central (via PubMed), Embase (via Ovid), SCOPUS, ScienceDirect, Google Scholar, SCI and Cochrane Library databases were undertaken. Seven randomized controlled trials assessing the outcomes of PSR and POMR were analyzed in accordance with the PRISMA statement. The risk of bias was assessed using the Rob2 tool.

RESULTS

According to the pooled analysis, POMR significantly reduced the incidence of IH compared to the PSR (OR 5.82 [95% CI 2.69, 12.58] P < 0.01) with a significantly higher seroma formation rate post-surgery (OR 0.35 [95% CI 0.18, 0.67] P < 0.01). Furthermore, the length of hospital stay (WMD -0.78 [95% CI -1.58, 0.02] P = 0.05) was significantly shorter for PSR compared to POMR group. Comparable effects were noted for reintervention, postoperative ileus, postoperative hematoma, postoperative mortality, long-term intervention and long-term deaths between the two groups.

CONCLUSIONS

POMR significantly reduces the risk of IH when compared to the PSR, with an increased risk of postoperative seroma formation and longer hospital stay. However, more RCTs with standardized protocols are needed for meaningful comparisons of the two interventions, along with longer duration of follow-up to assess the impact on the occurrence of IH.

The effect of obesity in laparoscopic transperitoneal adrenalectomy

Objective: Laparoscopic adrenalectomy is the gold standard for the resection of adrenal tumors. However, there are some technical difficulties, which may be due to the fact that adrenalectomy is rarely encountered in general surgery practice and has a high learning curve. In addition to these, obesity is another problem in laparoscopic adrenalectomies. In the present study, it was aimed to evaluate whether obesity affects perioperative and postop- erative complications after laparoscopic adrenalectomy.

Material and Methods: This is a retrospective comparative study carried out between December 2008 and June 2018. A total of 65 patients who un- derwent laparoscopic transperitoneal adrenalectomy were divided into two groups according to their Body Mass Index (BMI). Patients’ demographic data, perioperative and postoperative results were analyzed from hospital medical records.

Results: There were 30 non-obese and 35 obese patients. There was no significant difference between obese and non-obese patients in terms of op- eration time, peroperative complications and length of hospital stay. However, there was a statistically significant difference between the two groups for postoperative complications (p< 0.031). There was conversion to open surgery in four obese patients and in one patient in the non-obese group.

Conclusion: In obese patients, technical difficulties may be encountered during surgery due to increased adipose tissue, and postoperative complica- tion rates may increase. Nevertheless, laparoscopic transperitoneal adrenalectomy can be performed safely paying attention to the management of obesity-related complications.

Total endoscopic sublay mesh repair for umbilical hernias

Umbilical hernias constitute some of the most common surgical diseases addressed by surgeons. Endoscopic techniques have become standard of care together with the conventional open techniques for the treatment of umbilical hernias. Several different approaches were described to achieve laparoscopic sublay repair.We prospectively collected and reviewed the medical records of 10 patients with umbilical hernias underwent total endoscopic sublay repair (TES) at our institution from November 2017 to November 2019. All operations were performed by a same surgical team. The demographics, intraoperative details, and postoperative complications were evaluated.All TES procedures were successfully performed without conversion to an open operation. No intraoperative morbidity was encountered. The average operative time was 109.5 minutes (range, 80-140 minutes). All the patients resumed an oral diet within 6 hours after the intervention. The mean time to ambulation was 7.5 hours (range, 4-14 hours), and mean postoperative hospital stay was 2.2 day (range, 1-4 days). One patient developed postoperative seroma. No wound complications, chronic pain, or recurrence were registered during the follow-up.Initial experiences with this technique show that the TES is a safe, and effective procedure for the treatment of umbilical hernias.

Ventral Hernia Management in Obese Patients

Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.

Ventral incisional hernia case report: A therapeutic challenge

Incisional hernias are a very common condition and they still are considered to be a surgical challenge due to their recurrence rate. Smoking, obesity and age are risk factors for developing these abdominal wall defects. Despite recent advances in hernia repairs, the recurrence rates of hernias did not significantly diminished, even after the introduction of meshes. The aim of this article is to report a case of a ventral incisional hernia in a 37-year-old man and its successful treatment with a procedure known as the Alcino-Lázaro technique repair. This procedure has been shown to be very effective in incisional hernias, especially in obese patients. Furthermore, it is as cheap as it is reliable, since it can be performed without technological aid or expensive materials (mesh); thus, patients in low-income countries can greatly benefit from this procedure.

Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach?

PURPOSE

Ventral hernia repair has become a common procedure, but the way in which it is performed still depends on surgeon's skill, experience, and habit. The initial open approach is faced with extensive dissection and a high risk of infection and prolonged hospital stay. To tackle these problems, minimally invasive procedures are gaining interest. Several new techniques are emerging, but laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. We will discuss why laparoscopic IPOM is still a valuable approach in the treatment of primary non-complicated midline hernias and review the current literature.

METHODS

We performed a literature search across PubMed and MEDLINE using the following search terms: "Laparoscopic hernia repair", "Ventral hernia repair" and "Primary ventral hernia". Articles corresponding to these search terms were individually reviewed by the primary author and selected on relevance.

CONCLUSION

Laparoscopic IPOM still is a good approach for the efficient treatment of primary non-complicated midline hernias. Several techniques are emerging, but are faced with increased costs, technical difficulties, and low study patient volume. Further research is warranted to show superiority and applicability of these new techniques over laparoscopic IPOM, but until then laparoscopic IPOM should remain the go-to technique.

Retromuscular Sublay Technique for Ventral Hernia Repair

Rives and Stoppa described the sublay technique of hernia repair more than half a century ago, but it took almost three decades to become truly appreciated and even longer for its full clinical potential and benefits to be realized. Modifications to the original operation have significantly improved surgical approaches, postsurgical outcomes, and quality of life. The retromuscular approach requires technical expertise and a firm grasp of the anatomy. With constant substitution of the terms sublay, retrorectus, retromuscular, preperitoneal, and Rives-Stoppa throughout the literature, the nuances need to be distinguished to appreciate the surgical planes encountered during the operation. This article explains the origin of the nomenclature while clarifying these terms, describing the technique, highlighting outcomes, and discussing future considerations.