Modified Hernia Grading Scale to Stratify Surgical Site Occurrence after Open Ventral Hernia Repairs

The Great Debate: Mesh or No Mesh in Contaminated Hernia Repairs?

Abdominal hernia surgeries are commonly performed with many different approaches, and mesh utilization has become a cornerstone in hernia repair, ensuring durable outcomes with minimal recurrence risk. However, managing contaminated hernia repairs presents unique challenges due to the heightened risks of mesh infection. Recent advancements in lightweight macroporous polypropylene meshes offer promising solutions. Studies have highlighted the superiority of macroporous polypropylene meshes compared to primary suture repair and other mesh types in terms of reduced surgical site infection rates and lower hernia recurrence rates. Moreover, utilizing macroporous polypropylene mesh in the retrorectus plane is associated with a favorable salvage rate, underscoring its efficacy in contaminated hernia repairs. At the same time, contrary evidence suggests higher postoperative complications with mesh use in settings of clean-contaminated or contaminated fields. Most significant complications are increased infection rates and similar recurrence rates compared to mesh-free repairs. New synthetic mesh that is being marketed as having better outcomes than other types of mesh and potentially primary repair need to be carefully assessed as biologic mesh once used to also be touted as the mesh to use in such fields, but more research is showing higher complication rates. The risk of infection and consequent morbidity might outweigh the benefit of less recurrence risk with mesh use. Further research, including prospective studies with long-term follow-up, is warranted to elucidate optimal hernia repair strategies in contaminated fields and inform evidence-based practice guidelines.

Open Retromuscular Sugarbaker vs Keyhole Mesh Placement for Parastomal Hernia Repair: A Randomized Clinical Trial

Importance

Durable parastomal hernia repair remains elusive. There is limited evidence comparing the durability of the open retromuscular Sugarbaker and keyhole mesh configurations.

Objective

To determine if the open retromuscular Sugarbaker mesh placement technique would lower parastomal hernia recurrence rates.

Design, Setting, and Participants

In this single-center, randomized clinical trial, 150 patients with a permanent stoma and associated parastomal hernia who were candidates for open retromuscular parastomal hernia repair were enrolled and randomized from April 2019 to April 2022 and followed up for 2 years.

Interventions

Following intraoperative assessment to determine the feasibility of either technique, enrolled patients were randomized to receive either retromuscular Sugarbaker or keyhole synthetic mesh placement.

Main Outcomes and Measures

The primary outcome was parastomal hernia recurrence at 2 years. Secondary outcomes included mesh-related complications, wound complications, reoperations, as well as patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at 1 year and 2 years.

Results

A total of 150 patients were randomized, and with 91% follow-up at 2 years, there were 13 (17%) parastomal hernia recurrences in the retromuscular Sugarbaker arm and 18 (24%) in the keyhole arm (adjusted risk difference, -0.029; 95% CI, -0.17 to 0.153, and adjusted risk ratio, 0.87; 95% CI, 0.42 to 1.69). There were no statistically significant differences between the Sugarbaker and keyhole groups regarding reoperations for recurrence (2 vs 7, respectively), nonhernia intra-abdominal pathology (4 vs 10, respectively), stoma necrosis (1 vs 0, respectively), mesh-related complications (4 vs 1, respectively), patient-reported pain, abdominal wall-specific quality of life, stoma-specific quality of life, and decision regret at any time point.

Conclusions and Relevance

In the setting of open parastomal hernia repair, a retromuscular Sugarbaker mesh placement technique was not superior to a keyhole configuration 2 years after repair. Further innovation is necessary to improve parastomal hernia repair outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03972553.

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.

Long-term results with biosynthetic absorbable P4HB mesh in ventral abdominal wall repair: a multicentre analysis

BACKGROUND

The aim of this multicentre study was to analyse the outcomes of biosynthetic absorbable poly-4-hydroxybutyrate (P4HB) prosthesis implantation in patients undergoing ventral hernia repair (VHR) in the context of different degrees of contamination.

METHODS

From May 2016 to December 2021, a multicentre retrospective analysis of patients who underwent elective or urgent hernia repair with P4HB prosthesis was performed in seven hospitals in Spain and Portugal. Patients with a postoperative follow-up of less than 20 months and those within the theoretical period of prosthesis resorption were excluded from the study. Regarding the degree of contamination, patients were assessed according to the modified Ventral Hernia Working Group (VHWG) classification. Epidemiological data, hernia characteristics, surgical and postoperative variables (Clavien-Dindo classification) of these patients were analyzed. Risk factors related to long-term recurrence were studied by a multivariate analysis.

RESULTS

In 236 cases of P4HB prosthesis implantation, repair in cases of Grade 3 was the most frequent (49.1%), followed by Grade 2 in 42.3% of cases and Grade 1 in 8.4%. The most frequent complications were Grade 1, with the majority occurring during the first year. The overall rate of surgical site occurrences (SSO) was 30%. The hernia recurrence rate was 14.4% (n = 34), with a mean postoperative follow-up time of 41 months (22-61). The multivariate analysis showed that the onlay location of the mesh (OR 1.07; CI 1.42-2.70, p = 0.004) was a significant independent risk factor for recurrence.

CONCLUSIONS

The use of a P4HB bioresorbable mesh for the VHR with different degrees of contamination leads to favourable results overall, with an acceptable rate of hernia recurrence. The onlay location of the P4HB prosthesis is the main factor in recurrence in both elective and emergency settings.

Is Full Scrubbing Necessary Before Short Endourological Procedures to Reduce the Risk of Post-Operative Infection? A Retrospective Cross-Sectional Study

Background: Endoscopic surgery is now increasingly taking the place of open surgery in urology. Traditionally, endourological procedures are classified as clean-contaminated because the genitourinary tract is colonized by micro-flora, even in the case of sterile urine. The aim of this study was to determine whether a difference occurs in the infection rate after short endourological procedures using standard scrubbing and partial scrubbing techniques before the operations. Patients and Methods: This was a retrospective analysis of 397 patients who underwent a short endourological procedure, with all procedure durations lasting <30 min. Patients were divided into a first group who underwent operations using a full-scrub technique and a second group who underwent operations using a partial-scrub technique. All patients were followed up for the occurrence of urinary tract infections (UTIs). Both groups were compared for age, gender, and post-operative development of UTIs. Values of p < 0.05 were considered statistically significant. Results: Of the 397 patients, 200 and 197 underwent their procedures using the full-scrub and partial-scrub techniques, respectively. Females and males accounted for 142 (35.8%) and 255 (64.2%) patients, respectively. Only 18 (4.5%) patients developed documented UTIs and antibiotics were prescribed. Of the 18 patients diagnosed with post-operative UTIs, 10 (55.5%) had undergone partial-scrub operations and 8 (45.5%) had undergone full-scrub operations (p = 0.638). Conclusion: Our findings did not indicate any significant relationship between the risk of developing UTI after a short endourological procedure and the scrub technique used before the operation (partial or full scrub).

Impact of the ventral hernia working group's publication: a bibliometric analysis

PURPOSE

The Ventral Hernia Working Group (VHWG) proposed a ventral hernia grading guideline, primarily supported by expert opinion, recommending biologic mesh placement in high-risk patients. We investigated the relationship between this industry-sponsored guideline and discourse around ventral hernia repair (VHR).

METHODS

Medline platform from Web of Science's database identified publications "pre-VHWG"(1999-01-01 to 2009-12-31), and "post-VHWG"(2010-01-01 to 2020-12-31) describing VHR and complications or recurrence of VHR with the following comorbidities: COPD, smoking, diabetes, immunosuppression, or obesity. Poisson regression analyzed keyword frequency over time using logarithmically transformed data.

RESULTS

Of 1291 VHR publications identified pre-VHWG and 3041 publications identified post-VHWG, 172 (13.3%) and 642 (21.1%) publications respectively included prespecified keywords. The keyword groups "biologic"(IRR 3.39,95%CI1.34-11.4,p = 0.022) and "comorbid"(IRR 1.95, 95%CI1.09-3.74,p = 0.033) significantly increased with frequency after publication of the VHWG.

CONCLUSION

The VHWG publication likely contributed to a focus on comorbidities and biologic mesh in the ensuing literature within the field of VHR.

Does selective intraoperative music reduce pain following abdominal wall reconstruction? A double-blind randomized controlled trial

PURPOSE

Although intraoperative music is purported to mitigate postoperative pain after some procedures, its application has never been explored in abdominal wall reconstruction (AWR). We sought to determine whether intraoperative music would decrease early postoperative pain following AWR.

METHODS

We conducted a placebo-controlled, patient-, surgeon-, and assessor-blinded, randomized controlled trial at a single center between June 2022 and July 2023 including 321 adult patients undergoing open AWR with retromuscular mesh. Patients received noise-canceling headphones and were randomized 1:1 to patient-selected music or silence after induction, stratified by preoperative chronic opioid use. All patients received multimodal pain control. The primary outcome was pain (NRS-11) at 24 ± 3 h. The primary outcome was analyzed by linear regression with pre-specified covariates (chronic opioid use, hernia width, operative time, myofascial release, anxiety disorder diagnosis, and preoperative STAI-6 score).

RESULTS

178 patients were randomized to music, 164 of which were analyzed. 177 were randomized to silence, 157 of which were analyzed. At 24 ± 3 h postoperatively, there was no difference in the primary outcome of NRS-11 scores (5.18 ± 2.62 vs 5.27 ± 2.46, p = 0.75). After adjusting for prespecified covariates, the difference of NRS-11 scores at 24 ± 3 h between the music and silence groups remained insignificant (p = 0.83). There was no difference in NRS-11 or STAI-6 scores at 48 ± 3 and 72 ± 3 h, intraoperative sedation, or postoperative narcotic usage.

CONCLUSION

For patients undergoing AWR, there was no benefit of intraoperative music over routine multimodal pain control for early postoperative pain reduction.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05374096.

Cannabis smoking and abdominal wall reconstruction outcomes: a propensity score-matched analysis

PURPOSE

Despite increasing use of cannabis, literature on perioperative effects is lagging. We compared active cannabis-smokers versus non-smokers and postoperative wound morbidity and reoperations following open abdominal wall reconstruction (AWR).

METHODS

Patients who underwent open, clean, AWR with transversus abdominis release and retromuscular synthetic mesh placement at our institution between January 2014 and May 2022 were identified using the Abdominal Core Health Quality Collaborative database. Active cannabis-smokers were 1:3 propensity matched to non-smokers based on demographics and comorbidities. Wound complications, 30 day morbidity, pain (PROMIS 3a-Pain Intensity), and hernia-specific quality of life (HerQles) were compared.

RESULTS

Seventy-two cannabis-smokers were matched to 216 non-smokers. SSO (18% vs 17% p = 0.86), SSI (11.1% vs 9.3%, p = 0.65), SSOPI (12% vs 12%, p = 0.92), and all postoperative complications (46% vs 43%, p = 0.63) were similar between cannabis-smokers and non-smokers. Reoperations were more common in the cannabis-smoker group (8.3% vs 2.8%, p = 0.041), driven by major wound complications (6.9% vs 3.2%, p = 0.004). No mesh excisions occurred. HerQles scores were similar at baseline (22 [11, 41] vs 35 [14, 55], p = 0.06), and were worse for cannabis-smokers compared to non-smokers at 30 days (30 [12, 50] vs 38 [20, 67], p = 0.032), but not significantly different at 1 year postoperatively (72 [53, 90] vs 78 [57, 92], p = 0.39). Pain scores were worse for cannabis-smokers compared to non-smokers at 30 days postoperatively (52 [46, 58] vs 49 [44, 54], p = 0.01), but there were no differences at 6 months or 1 year postoperatively (p > 0.05 for all).

CONCLUSION

Cannabis smokers will likely experience similar complication rates after clean, open AWR, but should be counseled that despite similar wound complication rates, the severity of their wound complications may be greater than non-smokers.

Long-term outcomes of Madrid approach after TAR for complex abdominal wall hernias: a single-center cohort study

PURPOSE

Undeniably, in the last 2 decades, surgical approaches in the field of abdominal wall repair have notably improved. However, the best approach to provide a durable repair with low morbidity rate has yet to be determined. The purpose of this study is to outline our long-term results following the Transverse Abdominis Release (TAR) approach in patients with complex ventral hernias, focusing on the incidence of recurrence and overall patient satisfaction following surgery.

METHODS

This is a retrospective study on 167 consecutive patients who underwent TAR between January 2015 and December 2021 for primary or recurrent complex abdominal hernias. Of these, 117 patients who underwent the open Madrid approach with the use of a double mesh (absorbable and permanent synthetic mesh) were selected and analyzed. A quality of life questionnaire (EuraHS QoL) comparing the preoperative and the postoperative status was administered.

RESULTS

Between January 2015 and December 2021, we successfully treated 117 patients presenting with complex ventral defects using the double mesh technique (absorbable and permanent synthetic mesh). Of these, 26 (22.2%) were recurrent cases. At a median follow-up period of 37.7 months, there had been 1 (0.8%) case of recurrence and 8 cases (6.8%) of bulging. The QoL score was significantly improved when compared to the preoperative status in terms of cosmesis, body perception, and physical discomfort.

CONCLUSIONS

The Madrid approach for posterior component separation is associated with both a low perioperative morbidity and recurrence rate. In accordance with other studies, we demonstrated that the TAR with reconstruction according to the Madrid approach provides excellent results in the treatment of complex abdominal wall hernias, even at long-term follow-up.

Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release)

BACKGROUND

Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR.

METHODS

This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36 months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score.

RESULTS

The average follow-up was 38.3 ± 12.7 months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery.

CONCLUSIONS

This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.

Predictive factors for complexity in abdominal wall hernias: a literature scope review

INTRODUCTION

Abdominal wall hernias encompass both ventral and incisional hernias, often poorly classified regarding complexity in general. This study aims to conduct a review on the primary topics related to defining the complexity of ventral hernias.

METHODS

this is a scope review conducted following the guidelines recommended by the PRISMA-ScR directive. Searches were carried out in electronic databases including PubMed, LILACS, and EMBASE, using the descriptors: Abdominal Hernia, Hernia, Ventral Hernia, Incisional Hernia, Complex, Classification, Classify, Grade, Scale, and Definition. Combinations of these terms were employed when appropriate. Inclusion criteria encompassed articles with definitions and classifications of complex hernias, as well as those utilizing these classifications to guide treatments and patient allocation. Synonyms and related topics were also considered. Articles outside the scope or lacking the themes in their title or abstract were excluded. The database search was conducted up to July 29, 2023.

RESULTS

several hernia classifications were identified as useful in predicting complexity. For this study, we considered six main criteria: size and location, loss of domain, use of abdominal wall relaxation techniques, characteristics of imaging exams, status of the subcutaneous cellular tissue, and likelihood of recurrence.

CONCLUSION

complex abdominal wall hernias can be defined by characteristics analyzed collectively, relating to the patients previous clinical status, size and location of the hernia defect, status of subcutaneous cellular tissue, myofascial release techniques, and other complicating factors.

Robotic transversus abdominis release (TAR) for ventral hernia repairs is associated with low surgical site occurrence rates and length of stay despite increasing modifiable comorbidities

PURPOSE

Modifiable comorbidities (MCMs) have previously been shown to complicate postoperative wound healing occasionally leading to surgeon hesitancy to repair ventral hernias prior to preoperative optimization of comorbidities. This study describes the effects of MCMs on surgical site occurrences (SSOs) and hospital length of stay (LOS) following robotic transversus abdominis release (TAR) with poly-4-hydroxybutyrate (P4HB) resorbable biosynthetic mesh retromuscular sublay for ventral hernia repair in patients who had not undergone preoperative optimization.

METHODS

A single-surgeon retrospective review was performed for patients who underwent the robotic TAR procedure with P4HB mesh between January 2015 and May 2022. Patients were stratified by the amount of MCMs present: 0, 1, or 2 + . MCMs included obesity, diabetes, and current tobacco use. Patient data was analyzed for the first 60 days following their operation. Primary outcomes included 60-day SSO rates and hospital LOS.

RESULTS

Three hundred and thirty-four subjects met the inclusion criteria for SSO and prolonged LOS analysis. 16.8% had no MCM, 56.1% had 1 MCM, and 27% had 2 + MCMs. No significant difference in SSO was seen between the 3 groups; however, having 2 + MCMs was significantly associated with increased odds of SSO (odds ratio 3.25, P = .019). When the groups were broken down, only having a history of diabetes plus obesity was associated with significantly increased odds of SSO (odds ratio 3.54, P = .02). No group showed significantly increased odds of prolonged LOS.

CONCLUSION

2 + MCMs significantly increase the odds of SSO, specifically in patients who have a history of diabetes and obesity. However, the presence of any number of MCMs was not associated with increased odds of prolonged LOS.

Revisiting femoral hernia diagnosis rates by patient sex in inguinal hernia repairs

INTRODUCTION

Guidelines recommend MIS repairs for females with inguinal hernias, despite limited evidence. We investigated rates of femoral hernias intraoperatively noted during MIS and Lichtenstein repairs in females.

METHODS

ACHQC was queried for adult females undergoing inguinal hernia repair between January 2014-November 2022. Outcomes included identified femoral hernia and size, hernia recurrence, quality of life, and sex-based recurrence.

RESULTS

1357 and 316 females underwent MIS and Lichtenstein inguinal repair respectively. Femoral hernias were identified more frequently in MIS than open repairs (27%vs12%; (p ​< ​0.001). Most femoral hernias in MIS (61%) and Lichtenstein repairs (62%) were <1.5 ​cm(p ​< ​0.001). Identification rates of femoral hernias >3 ​cm were 1% overall(p ​= ​0.09). Surgeon and patient-reported recurrences were similar between approaches at 1-5-years for females(p ​> ​0.05 for all) and similar between sexes(p ​> ​0.05).

CONCLUSION

Most incidental femoral hernias are small and both repair approaches demonstrated similar outcomes. The recommendation for MIS inguinal hernia repairs in females is potentially overstated.

Robotic repair of moderate-sized midline ventral hernias reduced complications, readmissions, and length of hospitalization compared to open techniques

PURPOSE

To compare outcomes of robotic and open repair for uncomplicated, moderate-sized, midline ventral hernias.

METHODS

From 2017 to 2021, patient characteristics and 30 day outcomes for all ventral hernias at our center were prospectively collected. We studied hernias potentially suitable for robotic repair: elective, midline, 3-10 cm rectus separation, no prior mesh, and no need for concomitant procedure. Robotic or open repair was performed by surgeon or patient preference. The primary outcome was any complication using Clavien-Dindo scoring. Secondary outcomes were operative time, length-of-stay, and readmissions. Regression identified predictors of complications.

RESULTS

Of 648 hernias repaired, 70 robotic and 52 open repairs met inclusion criteria. The groups had similar patient demographics, co-morbidities, and hernia size, except that there were more immunosuppressed patients in the open group (11 versus 5 patients, p = 0.031). Complications occurred after 7 (13%) open repairs versus 2 (3%) robotic repairs, p = 0.036. Surgical site infection occurred after four open repairs but no robotic repair, p = 0.004. Length-of-stay averaged almost 3 days longer after open repair (4.3 ± 2.7 days versus 1.5 ± 1.4 days, p = 0.031). Readmission occurred after 6 (12%) oppen repairs but only 1 (1%) robotic repair. A long-term survey (61% response rate after mean follow-up of 2.8 years) showed that the HerQLes QOL score was better after robotic repair (46 ± 15 versus 40 ± 17,  = 0.049). In regression models, only open technique predicted complications.

CONCLUSIONS

Robotic techniques were associated with fewer complications, shorter hospitalization, fewer infections, and fewer readmissions compared to open techniques. Open surgical technique was the only predictor of complications.

Open retromuscular keyhole compared with Sugarbaker mesh for parastomal hernia repair: Early results of a randomized clinical trial

BACKGROUND

Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days.

METHODS

This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications.

RESULTS

A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days.

CONCLUSION

Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio.

Tipping the scale in abdominal wall reconstruction: An analysis of short- and long-term outcomes by body mass index

BACKGROUND

Morbid obesity, with a body mass index 35 kg/m2, is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes.

METHODS

Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh-to-hernia size ratio.

RESULTS

A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14-1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13-1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m2 group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02-1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year.

CONCLUSION

Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m2 should not be used to deny symptomatic patients abdominal wall reconstruction.

Mesh Strip Repair for Midline Ventral Hernias: A Case Series

Background

Polypropylene mesh strip repair is a novel method of hernia closure. Currently, there is limited representation in the literature regarding both the reproducibility of this method and its outcomes. The present study sought to analyze a second institution's experience with fascial closure using the mesh strip technique with long-term follow-up.

Methods

A retrospective review of all patients undergoing abdominal wall reconstruction by the senior author was performed. Patients undergoing midline ventral hernia repair with mesh strip only fascial closure and greater than 1 year follow-up were including for analysis. Demographic data; operative details; and outcomes, specifically presence and timing of hernia recurrence, were recorded.

Results

Eighteen patients met inclusion criteria. Average follow-up was 860 ± 307 days. Nine patients (50%) had recurrence of their hernia after repair. Average time to recurrence was 602 ± 406 days, with the earliest recurrence occurring at 126 days postoperatively. Seven patients (39%) underwent concurrent anterior component separation (four unilateral, three bilateral), of which there were three recurrences, all occurring in patients with bilateral anterior component separation.

Conclusions

The mesh strip repair is a novel technique that shows uncertain reproducibility of outcomes, specifically with concurrent component separation techniques. With the recent Food and Drug Administration approval of a mesh suture, further multi-institutional analysis will allow for better characterization of the outcomes and indications for this technique.

Age is just a number: The role of advanced age in predicting complications following ventral hernia repair with component separation

BACKGROUND

While advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear.

METHODS

A single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years).

RESULTS

Of 219 patients who underwent VHR with CST, 114 patients (52.1 ​%) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p ​= ​0.002) and COPD was positively associated with seroma development (OR 20.1, p ​= ​0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p ​= ​0.766).

CONCLUSIONS

VHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.

Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure

PURPOSE

Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application.

METHOD

A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated.

RESULTS

Imaging post-BTA revealed hernia width reduction of 1.9 cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1 cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%.

CONCLUSION

BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

Does a "hernia center" label provide better 30-day outcomes following elective ventral hernia repair?: An analysis of the ACHQC database

INTRODUCTION

Currently, there is no agreed upon definition of a designated hernia center (DHC) and no study has investigated the association of hernia center designation with ventral hernia repair (VHR) outcomes. We sought to investigate the current utilization of DHC and the association of hernia center designation with VHR outcomes.

METHODS

All patients who underwent elective, ventral hernia repair with mesh with 30-day follow-up from 2013 through 2020 were in the Americas Hernia Society Quality Collaborative (ACHQC) database. Patients were divided into two groups: those that underwent VHR at a DHC and those that underwent VHR at a non-designated hernia center site (NDHC). Using a 1:1 matched analysis, differences in the incidence of 30-day wound events, the total number of 30-day complications, one-year ventral hernia recurrence rates, and 30-day and one-year patient reported outcomes were compared between DHC and NDHC.

RESULTS

A total of 261 sites were included in our analysis; 78 (30%) were identified as DHC. After matching, there were 14,186 VHRs available for analysis. There was no significant difference in 30-day wound morbidity events. Patients who underwent VHR at NDHC were less likely to experience any 30-day complication or 1-year hernia recurrence while patients who underwent VHR at DHC had a statistically significant greater improvement in their HerQLes scores at one-year postoperatively.

CONCLUSIONS

There is currently no clear superiority to VHR at a DHC. The ACHQC may self-select for surgeons invested in hernia repair outcomes regardless of hernia center designation. More standardized criteria for a hernia center are required in order to positively influence the value of hernia care delivered in the United States.

Hernia Formation: Risk Factors and Biology

The incidence of ventral hernias in the United States is in increasing. Herein, the author details the etiology of congenital and acquired ventral hernias as well as the risk factors associated with the development of each of these types of ventral hernias.

Does smoking influence the clinical outcomes of robotic ventral hernia repair? A propensity score matching analysis study

The purpose of this study is to compare the clinical outcomes of robotic ventral hernia repair (RVHR) between smokers and non-smokers. Data for patients undergoing RVHR between 2012 and 2022 were collected. Patients were assigned to either smoking (+) or smoking (-) groups, according to their smoking status in the last 3 months prior to their procedure. Pre-, intra- and postoperative variables including surgical site occurrences (SSO) and infections (SSI), and hernia recurrence were analyzed after a propensity score matching analysis based on the patients' demographics and hernia's characteristics. Each group consisted of 143 patients matched according to their preoperative characteristics. There were no differences in terms of demographics and hernia characteristics. Intraoperative complications occurred at a comparable rate between both groups (p = 0.498). Comprehensive Complication Index® and all complication grades of the Clavien-Dindo classification were similar between both groups. Surgical site occurrences and infections did not differ either [smoking (+) vs. smoking (-): 7.6% vs 5.4%, p = 0.472; 5 vs. 0, p = 0.060, respectively). Rates of SSOs and SSIs that required any intervention (SSOPI) were similar in both groups [smoking (+): 3.1% vs. smoking (-): 0.8%, p = 0.370]. With a mean follow-up of 50 months for the cohort, recurrences rates were also comparable with 7 recorded in the smoking (-) versus 5 in the smoking (+) group (p = 0.215). Our study showed comparable rates of SSOs, SSIs, SSOPIs, and recurrence between smokers and non-smokers following RVHR. Future studies should compare the open, laparoscopic, and robotic approaches in smokers.

Ventral hernia repair with concurrent intra-abdominal surgery: Results from an eleven-year population-based cohort in Sweden

BACKGROUND

One remaining question in ventral hernia repair is whether to perform concurrent abdominal surgery or plan two-stage procedures. The aim was to explore the risk for reoperation and mortality due to surgical complication during index admission.

METHOD

Eleven-year data were retrieved from the National Patient Register and 68,058 primary surgical admissions were included, divided into minor and major hernia surgery and concurrent abdominal surgery. Results were evaluated by logistic regression analysis.

RESULTS

The risk for reoperation during index admission was higher for patients with concurrent surgery. Major hernia surgery and major concurrent surgery had an OR 37.9 compared to major hernia surgery only. Mortality rate within 30 days increased, OR 9.32. The combined risk for serious adverse event was accumulative.

CONCLUSION

These results stress the importance of critically evaluating needs for and planning of concurrent abdominal surgery during ventral hernia repair. Reoperation rate was a valid and useful outcome variable.

Do antiplatelets and anticoagulants have an impact on the clinical outcomes of robotic ventral hernia repair?

BACKGROUND

We sought to study the impact of antithrombotics(antiplatelets and anticoagulants) on robotic ventral hernia repair(RVHR).

METHODS

RVHR cases were divided into antithrombotic (AT) (-) and AT (+) groups. After comparing both groups, a logistic regression analysis was performed.

RESULTS

611 patients had no AT-medication. The AT(+) group had 219 patients of which 153 were only on antiplatelets, 52 only on anticoagulants, and 14(6.4%) patients on both antithrombotics. Mean age, American Society of Anesthesiology scores, and comorbidities were significantly higher in the AT(+) group. Intraoperative blood loss was greater in the AT(+) group. Postoperatively, the AT(+) group had greater rates of Clavien-Dindo grade-II and IV-a complications(p=0.001, and p=0.013, respectively), and postoperative hematomas(p=0.013). Mean follow-up was greater than 40 months. Age[Odds Ratio(OR): 1.034] and anticoagulants(OR: 3.121) were associated with increased bleeding-related events.

CONCLUSION

There were no associations between maintained antiplatelet therapy and postoperative bleeding-related events in RVHR whereas age and anticoagulants had the highest association.

Comparison of Two Versus Three Bilateral Botulinum Toxin Injections Prior to Abdominal Wall Reconstruction

Background: Intramuscular injection of botulinum toxin A (BTA) induces a temporary muscle paralysis. In patients with a ventral hernia, preoperative injection of BTA in the muscles of the lateral abdominal wall (LAW) leads to thinning and lengthening of these muscles, making fascial closure more likely. In many hernia centres, treatment with BTA prior to abdominal wall reconstruction has therefore become standard care. However, evidence on the optimal BTA strategy is lacking. Methods: In this single-centre retrospective study, we analysed a consecutive cohort of ventral hernia patients that underwent bilateral BTA injections prior to abdominal wall reconstruction with available CT before and after BTA. We only included patients that were treated with exactly 600 units of Dysport®, diluted into 120 mL of saline, via either two- or three injections on each side into all three LAW muscle layers. The primary outcome was the change in LAW muscle length and thickness, comparing CT measures from before BTA and 4-6 weeks after the injections. Results: We analysed 67 patients; 30 had received two injections bilaterally and 37 had received three injections bilaterally. Baseline data showed no significant differences in LAW muscle thickness or length between groups. In both groups, the median LAW muscle thickness decreased with 0.5 cm (p < 0.001). The LAW muscle length increased with 0.9 cm (p = 0.001) and 1.2 cm (p < 0.001) in the two- and three bilateral injection group, respectively. The BTA-induced changes in LAW thickness and length were not significantly different between both groups (p = 0.809 and p = 0.654, respectively). Discussion: When using the exact same dosage and distribution volume of BTA in patients with a complex abdominal wall defect, two injections bilaterally in the lateral abdominal wall muscles are as effective as three injections bilaterally.

The influence of a multidisciplinary team meeting and prehabilitation on complex abdominal wall hernia repair outcomes

PURPOSE

Surgical site occurrences after transversus abdominis release in ventral hernia repair are still reported up to 15%. Evidence is rising that preoperative improvement of risk factors might contribute to optimal patient recovery. A reduction of complication rates up to 40% has been reported. The aim of this study was to determine whether prehabilitation has a favorable effect on the risk on wound and medical complications as well as on length of stay.

METHODS

A retrospective cohort study was performed in a tertiary referral center for abdominal wall surgery. All patients undergoing ventral hernia repair discussed at multidisciplinary team (MDT) meetings between 2015 and 2019 were included. Patients referred for a preconditioning program by the MDT were compared to patients who were deemed fit for operative repair by the MDT, without such a program. Endpoints were patients, hernia, and procedure characteristics as well as length of hospital stay, wound and general complications.

RESULTS

A total of 259 patients were included of which 126 received a preconditioning program. Baseline characteristics between the two groups were statistically significantly different as the prehabilitated group had higher median BMI (28 vs 30, p < 0.001), higher HbA1c (41 vs 48, p = 0.014), more smokers (4% vs 25%, p < 0.001) and higher HPW classes due to more patient factors (14% vs 48%, p < 0.001). There were no significant differences in intra-operative and postoperative outcome measures.

CONCLUSIONS

This study showed prehabilitation facilitates patients with relevant comorbidities achieving the same results as patients without those risk factors. The indication of a preconditioning program might be effective at the discretion of an MDT meeting. Further research could focus on the extent of such program to assess its value.

Fully resorbable poly-4-hydroxybutyrate (P4HB) mesh for soft tissue repair and reconstruction: A scoping review

Background

Poly-4-hydroxybutyrate (P4HB) is a fully resorbable, biologically-produced polymer with a strength and flexibility comparable to permanent synthetic polymers. The objective was to identify/summarize all peer-reviewed publications involving P4HB mesh.

Methods

A scoping review was conducted within PubMed and included articles published through October 2022.

Results

A total of n = 79 studies were identified (n = 12 in vitro/bench; n = 14 preclinical; n = 6 commentaries; n = 50 clinical). Of the clinical studies, n = 40 reported results applicable to hernia and n = 10 to plastic/reconstructive surgery and involved patients of all Centers for Disease Control (CDC) wound classes and Ventral Hernia Working Group (VHWG) grades.

Conclusion

P4HB mesh provides long-term hernia repair strength and exhibits promising clinical outcomes beyond its resorption period. Future studies should include randomized controlled trials comparing P4HB to other biomaterials, as well as optimal patient selection, operative technique, long-term outcomes, minimization of potential mesh-related complications, and potential contraindications/complications for P4HB in hernia/abdominal wall reconstruction.

A computed tomography study investigating the effects of botulinum toxin injections prior to complex abdominal wall reconstruction

OBJECTIVE

To explore how intramuscular injection of botulinum toxin A (BTA) affects the lateral abdominal wall (LAW) musculature, abdominal- and hernia dimensions, and muscle structure on computed tomography (CT) in patients scheduled for complex abdominal wall reconstruction (CAWR).

METHODS

Retrospective analysis of prospectively registered patients who received bilateral intramuscular BTA injections into all three muscles of the LAW. Only patients for which a CT was available before and 3-6 weeks after BTA treatment prior to surgery were analyzed.

RESULTS

Fifty-two patients were analyzed. Median hernia width in all patients decreased with 0.4 cm (IQR - 2.1;0.6) (p = 0.023). Median intra-abdominal transverse diameter increased with 0.9 cm (IQR - 0.2;3.3) (p = 0.001) and the intra-abdominal anterior-posterior diameter decreased with 0.5 cm (IQR - 1.3;0.5) (p = 0.017), making the abdomen more oval. Median LAW muscle length increased with 0.9 cm (IQR 0.0;2.4) per side (p < 0.001), muscle thickness decreased with 0.5 cm (IQR - 0.8;- 0.2) (- 25.0%) per side (p < 0.001), and muscle mass decreased with 3.9 cm2 (IQR - 6.4;-1.5) (- 15.8%) per side (p < 0.001). Median HU of the psoas muscles (density) increased with 4.8 HU (IQR 0.4;9.7) (10.3%) per side (p < 0.001). Effects of BTA were more pronounced in patients with a loss of domain (LoD) ≥ 20%.

CONCLUSIONS

The main effect of BTA injections is elongation and thinning of the LAW muscles, more than a decrease in hernia width. Concomitantly, the abdomen becomes more oval. An increase of psoas muscles density is seen, associated with offloading of the LAW muscles. Patients with large LoD have a proportionally higher effect of BTA.

Microbiological epidemiology and antibiotic susceptibility of infected meshes after prosthetic abdominal wall repair

INTRODUCTION

Infectious complications of parietal mesh after prosthetic abdominal wall repair are rare. Their management is complex. Furthermore, the emergence of bacterial resistance, the presence of a foreign material, the need to continue an extended antibiotic therapy, and the choice of an appropriate treatment are crucial. The objective of this study is to access the microbiological epidemiology of infected parietal meshes in order to optimize the empirical antibiotic therapy.

METHODS

Between January 2016 and December 2021, a monocentric and retrospective study was performed in patients hospitalized for infected parietal meshes at Avicenne hospital, in Paris area. Clinical and microbiological data such as antibiotic susceptibility were collected.

RESULTS

Twenty-six patients with infected parietal meshes have been hospitalized during this period. Meshes were in preaponevrotic positions (n=10; 38%), retromuscular (n=6; 23%) and intraperitoneal (n=10; 38%). Among the 22 (84.6%) documented cases of infections, 17 (77.3%) were polymicrobial. A total of 54 bacteria were isolated, 48 of which had an antibiogram available. The most frequently isolated bacteria were: Enterobacterales (n=19), Enterococcus spp. (n=11) and Staphylococcus aureus (n=6), whereas anaerobes were poorly isolated (n=3). Concerning these isolated bacteria, amoxicillin-clavulanic acid, metronidazole-associated cefotaxime, piperacillin-tazobactam and meropenem were susceptible in 45.5%, 68.2%, 63.6%, 77.2%, of cases, respectively.

CONCLUSION

This work highlights that infections of abdominal parietal meshes may be polymicrobial and the association amoxicillin-clavulanic acid cannot be used as a probabilist antibiotic therapy because of the high resistance rate in isolated bacteria. The association piperacillin-tazobactam appears to be a more adapted empirical treatment to preserve carbapenems, a broad-spectrum antibiotic class.

Abdominal Wall Reconstruction with Retrorectus Self-Adhering Mesh: A Single-Center Long-Term Follow-Up

BACKGROUND

Mesh repair has been demonstrated to be superior to suture alone in ventral hernia repair. In a previous short-term pilot study, the authors found lower postoperative narcotic requirements with self-adhering mesh. The aim of this study was to follow-up on that pilot study, using long-term data.

METHODS

This is a retrospective review of a prospectively collected database. All patients who underwent ventral hernia repair with retrorectus mesh and who had at least a 12-month follow-up were reviewed. Comparisons were performed between patients who received self-adhering mesh and those who received transfascially sutured mesh, using matched-pair analysis, examining perioperative outcomes, surgical-site occurrences, and hernia recurrence/bulge.

RESULTS

Forty-two patients were included in the study, with 21 patients undergoing repair with transfascially sutured mesh and 21 patients receiving self-adhering mesh. Average length of follow-up was 1078 days. There were no significant differences between the two groups in baseline characteristics. Patients receiving self-adhering mesh had significantly shorter surgery, and a shorter hospital length of stay. They also had a tendency toward lower narcotic requirements. There were no significant differences in the rate of surgical-site occurrences, hernia recurrences, or bulge between the two groups.

CONCLUSIONS

This long-term study shows that self-adhering mesh in ventral hernia repair results in similar long-term outcomes to transfascially sutured mesh, with shorter surgery, shorter length of stay, and a tendency toward improved pain control. These findings mirror the known advantages of self-adhering mesh in inguinal hernia repair. Further research is needed to study the incidence of chronic pain and the cost-effectiveness of self-adhering mesh.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Skin closure following abdominal wall reconstruction: three-layer skin suture versus staples

Skin closure following abdominal wall reconstruction (AWR) has received little attention, even though these patients have demonstrated insufficient wound healing. This study assessed the postoperative wound-related complications and patient-reported outcomes after skin closure using single- or triple layer closure following AWR. This was a retrospective study at a University Hospital from 2016 to 2018. Patients were grouped into a single-layer cohort (SLC) and a triple-layer cohort (TLC). Skin incisions closed with either technique were compared. Postoperative complications were registered from chart review (SLC: n = 48, TLC: n = 40). Patient reported-outcomes were assessed through the Patient Scar Assessment Questionnaire (PSAQ) and the Hernia Related Quality of Life survey. A total of 51 patients were included (SLC: n = 26, TLC: n = 25). There was no difference in wound complications after single- or triple-layer skin closure; seroma (SLC: 16.7% vs. TLC: 15%, p = 1.00), surgical site infection (SLC: 4.2% vs. TLC: 7.5%, p = .834), hematoma (SLC: 6.2% vs. TLC: 2.5%, p = .744) and wound rupture (SLC: 2.1% vs. TLC: 2.5%, p = 1.00). Patients who had incisions closed using single-layer closure were more satisfied; PSAQ satisfaction with scar symptoms (SLC: 6.7 points (IQR 0.0-18.3) vs. TLC: 26.7 points (IQR 0.0-33.3), p = .039) and scar aesthetics (SLC 25.9 points (IQR 18.5-33.3) vs. TLC: 37.0 (IQR 29.6-44.4), p = .013). There was no difference in 30-day wound complications after either skin closure technique. The results favoured the single-layer closure technique regarding the cosmetic outcome.Abbreviations: AWR: abdominal wall reconstruction; SLC: single-layer cohort; TLC: triple-layer cohort; PSAQ: patient scar assessment questionnaire; IH: incisional hernia; QOL: quality of life; BMI: body mass index; HerQLes: hernia-related quality of life; ASA: American Society of Anesthesiologists; SSO: surgical site occurence; SSI: surgical site infection; LOS: length of stay; RCT: randomized controlled trial.

Ventral hernia repair in high-risk patients and contaminated fields using a single mesh: proportional meta-analysis

PURPOSE

The use of mesh is a common practice in ventral hernia repair (VHR). Lack of consensus on which prosthetic material works better in different settings remains. This meta-analysis aims to summarize the available evidence on hernia recurrence and complications after repair with synthetic, biologic, or biosynthetic/bioabsorbable meshes in hernias grade 2-3 of the Ventral Hernia Working Group modified classification.

METHODS

A literature search was conducted in January 2021 using Web of Science (WoS), Scopus, and MEDLINE (via PubMed) databases. Randomized Controlled Trials (RCTs) and observational studies with adult patients undergoing VHR with either synthetic, biologic, or biosynthetic/bioabsorbable mesh were included. Outcomes were hernia recurrence, Surgical Site Occurrence (SSO), Surgical Site Infection (SSI), 30 days re-intervention, and infected mesh removal. Random-effects meta-analyses of pooled proportions were performed. Quality of the studies was assessed, and heterogeneity was explored through sensitivity analyses.

RESULTS

25 articles were eligible for inclusion. Mean age ranged from 47 to 64 years and participants' follow-up ranged from 1 to 36 months. Biosynthetic/bioabsorbable mesh reported a 9% (95% CI 2-19%) rate of hernia recurrence, lower than synthetic and biologic meshes. Biosynthetic/bioabsorbable mesh repair also showed a lower incidence of SSI, with a 14% (95% CI 6-24%) rate, and there was no evidence of infected mesh removal. Rates of seroma were similar for the different materials.

CONCLUSIONS

This meta-analysis did not show meaningful differences among materials. However, the best proportions towards lower recurrence and complication rates after grade 2-3 VHR were after using biosynthetic/slowly absorbable mesh reinforcement. These results should be taken with caution, as head-to-head comparative studies between biosynthetic and synthetic/biologic meshes are lacking. Although, biosynthetic/bioabsorbable materials could be considered an alternative to synthetic and biologic mesh reinforcement in these settings.

Posterior component separation with TAR: lessons learned from our first consecutive 52 cases

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39-76) and Body mass index (BMI kg/m²) of 31.2 (24-45). More than half of patients (58%) were active smokers. Mean defect width was 13.6 cm (range 6-30) and mean defect area was about 267.9 cm². Mean operative time was 228 min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7 days. 27% of patients developed minor complications (Clavien-Dindo grade I-II) and one case (1.9%) major complication (Clavien-Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28 months. In Univariate analysis Bio-A surface > 600 cm² and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600 cm² was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien-Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients.

At least ninety days of follow-up are required to adequately detect wound outcomes after open incisional hernia repair

INTRODUCTION

Incisional hernia repair (IHR) carries a high risk of wound complications. Thirty-day outcomes are frequently used in comparative-effectiveness research, but may miss a substantial number of surgical site occurrences (SSO) including surgical site infection (SSI). The objective of this study was to determine an optimal length of follow-up to detect SSI after IHR.

METHODS

All adult patients undergoing open IHR at a single academic center over a 3 year period were reviewed. SSIs, non-infectious SSOs, and wound-related readmissions were recorded up to 180 days. The primary outcome was the proportion of SSIs detected at end-points of 30, 60, and 90 days of follow-up. Time-to-event analysis was performed for all outcomes at 30, 60, 90, and 180 days. Logistic regression was used estimate the relative risk of SSI for relevant risk factors.

RESULTS

A total of 234 patients underwent open IHR. Median follow-up time of 102 days. Overall incidence of SSI was 15.8% with median time to occurrence of 23 days. Incidence of non-infectious SSO was 33.2%, and SSO-related readmission was 12.8%. At 30, 60, and 90 days sensitivity was 81.6%, 89.5%, and 92.1 for SSI, and 46.7%, 76.7%, and 83.3% for readmission. In regression analysis, body mass index (RR 1.08, 95% CI 1.00, 1.15, p = 0.04) anterior component separation (RR 4.21, 95% CI 2.09, 6.34, p = 0.003), and emergency surgery (RR 3.25, 95% CI 1.47, 5.02, p = 0.01), were independently associated with SSI after adjusting for age, sex, contamination class, and procedure duration.

CONCLUSION

A considerable proportion of SSIs occurred beyond 30 days, but 90-day follow-up detected 92% of SSIs. Follow-up to 90 days captured only 83% of SSO-related readmissions. These results have implications for the design of trials evaluating wound complication after open IHR, as early endpoints may miss clinically relevant outcomes and underestimate the number needed to treat. Where possible, we recommend a minimum follow-up of 90 days to estimate wound complications following open IHR.

Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review

All abdominal wall reconstructions find themselves on a scale, varying between simple to highly complex procedures. The level of complexity depends on many factors that are divided into patient comorbidities, hernia characteristics, and wound characteristics. Preoperative identification of modifiable risk factors provides the opportunity for patient optimization. Because this so called prehabilitation greatly improves postoperative outcome, reconstructive surgery should not be scheduled before all modifiable risk factors are optimized to a point where no further improvement can be expected. In this review, we discuss the importance of preoperative risk factor recognition, identify modifiable risk factors, and utilize options for patient prehabilitation, all aiming to improve postoperative outcome and therewith long-term success of the reconstruction.

Slowly absorbable mesh versus standard care in the management of contaminated midline incisional hernia (COMpACT-BIO): a multicentre randomised controlled phase III trial including a health economic evaluation

INTRODUCTION

Incisional hernia (IH) is the most frequent mid-term and long-term complication after midline laparotomy. The current standard treatment includes repair using a mesh. In a contaminated field, the use of a non-absorbable mesh increases the risk of surgical site infection and the costs. Slowly absorbable meshes are safe in contaminated fields, but no data have been reported regarding their long-term recurrence rate. COMpACT-BIO is a multicentre prospective randomised controlled phase III trial designed to compare the 3-year recurrence rate in patients undergoing contaminated IH repair with either a slowly absorbable mesh or standard care.

METHODS

In patients undergoing midline IH repair in a contaminated surgical field (grade III of the modified Ventral Hernia Working Group classification), the COMpACT-BIO study compares the use of a slowly absorbable mesh with that of conventional care according to standardised surgical procedures (primary closure, non-absorbable synthetic mesh or biologic mesh, at the discretion of the surgeon). Randomisation is done during surgery before closure the fascia with an allocation ratio of 1:1. The choice of the slowly absorbable mesh is left to the criteria of each centre. The primary endpoint is the proportion of patients with scan-confirmed IH recurrence within 3 years after repair.

ETHICS/DISSEMINATION

This trial is conducted in compliance with international standards for research practice and reporting. Written informed consent will be obtained from patients prior to inclusion. All data were identified and anonymised prior to analysis. The protocol has been approved by an Institutional Review Board (2020-A0823-36/SI:20.07.03.66831), and will be conducted in compliance with the CONSORT (Consolidated Standards of Reporting Trials) statement. Results will be submitted for publication in peer-reviewed medical journals and presented to patients and healthcare professionals.

PROTOCOL VERSION

Version 2-13 October 2020.

TRIAL REGISTRATION NUMBER

NCT04597840.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds.

METHODS

A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both.

RESULTS

In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm² vs. 208 ± 155cm²; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection.

CONCLUSIONS

Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

Treatment of enterocutaneous fistula: a systematic review and meta-analysis

BACKGROUND

Enterocutaneous fistula (ECF) is an abnormal communication between the gastrointestinal tract and skin, with a myriad of etiologies and therapeutic options. Management is influenced by etiology and specifics of the ECF, and patient-related factors. The aim of this study was to assess overall success, recurrence, and mortality rates of treatment for ECF.

MATERIALS

A systematic search of PubMed and Google Scholar was performed through October 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports, reviews, animal studies, studies not reporting outcomes, had no available English text, included patients < 16 years old or those assessing other abdominocutaneous/internal fistulas were excluded.

RESULTS

Fifty-three studies, between 1975 and 2020, incorporating 3078 patients were included. Patient age ranged between 16 and 87 years with a male:female ratio of 1.14:1. ECF developed postoperatively in 89.4%. Other common etiologies were inflammatory bowel disease, trauma, malignancy, and radiation. At least 28% of patients had complex fistulae (reported in 18 studies). Most common fistula site was small bowel. In 34 publications, 62.4% (n = 1371) patients received parenteral nutrition. In 45 publications, 72.5% underwent surgery to treat the fistula. Meta-analysis revealed an 89% healing rate; recurrence rate after initial successful treatment was 11.1%, and mortality rate was 8.5%. In a subgroup of patients who underwent combined ECF takedown and abdominal wall reconstructions (n = 315), 78% achieved fascial closure, mesh was used in 72%, hernia, and fistula recurrence rates were 19.7% and 7.6%, respectively.

CONCLUSIONS

Treatment of ECF must be individualized according to specific etiology and location of the fistula and the patient's associated conditions.

Endoscopic transversus abdominis release in the treatment of midline incisional hernias: a prospective single-center observational study on 100 patients

BACKGROUND

For W2-3 incisional hernias of the midline, a component separation is often needed to achieve closure of the fascia during repair with a mesh. Posterior component separation has been initially performed via open surgical approach, but more recently interest in minimally invasive reconstruction has grown. The aim of this work is to describe the technical aspects of endoscopic hernia repair with posterior component separation and to assess its feasibility in midline incisional hernias, based on the analysis of the results.

METHODS

We prospectively evaluated and analyzed patients with midline incisional hernias who underwent endoscopic posterior component separation by transversus abdominis release (TAR).

RESULTS

A group of 100 patients was operated between April 2017 and September 2021. The median follow-up was 27 ± 13.5 months, mean age 59 ± 10.2 years, ASA 2.5 ± 0.7; 94% of patients had comorbidity. There were 7 (7%) complications observed in the early postoperative period-retromuscular hematoma (1), infection of the retromuscular space (4), and thrombophlebitis of superficial veins (2). In 4 (4%) patients, late complications were observed-persistent seroma (3) and chronic pain (1). There were no hernia recurrences in the follow-up period.

CONCLUSION

The use of TAR endoscopic separation can reduce the number of unfavorable surgical site events, compared to the published data on a similar open surgery, while maintaining a low recurrence rate.

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital

Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7 days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90 days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.

Validation of ventral hernia risk score in predicting surgical site infections

PURPOSE

Ventral hernia risk score (VHRS) is a risk assessment tool for predicting the development of surgical site infection (SSI) developed in the Veterans Affairs population by Berger et al. The score was externally validated by the same study group in a diverse population in another study. It was also shown to be better than the existing Centre for Diseases (CDC) wound class and Ventral Hernia Working Group (VHWG) models. Our study aims to test the performance of the score in an Asian-Indian population.

METHODS

A prospective database of ventral hernia repairs done in a tertiary care centre between February 2019 and December 2020 was utilized for the study. All patients with a minimum follow-up of 1-month period were included in the study. The CDC definition of SSI was used. The VHRS, VHWG, and CDC class of each of the patients was determined. Receiver-Operating curves (ROC) of the scores and area under the curves (AUC) were used to compare the three scores.

RESULTS

A total of 120 patients were included. During the course of our study, a total of 33 patients developed SSI (27.5%). Important factors which seemed to predict SSI were median operating time, CDC incision class, concomitant hernia repair, and creating skin flaps. The AUC of the VHRS score was 0.76 which was higher than those of VHWG (0.61) and CDC (0.58).

CONCLUSION

Our study externally validates the novel VHRS which outperforms both CDC incision class and VHWG in predicting SSI following open ventral hernia repair, especially in a group with lower BMI compared to the previous reports. Trial registration No CTRI/2020/07/026289 registered on 01/07/2020.

Chronological age does not predict postoperative outcomes following transversus abdominis release (TAR)

BACKGROUND

Transversus abdominis release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TAR is not a low risk operation, particularly in older adults who are disproportionately affected by multiple age-related risk factors. While past studies have suggested that age alone inconsistently predicts patient outcomes, data regarding age's effect on postoperative outcomes and wound complications following a TAR are lacking.

METHODS

Patients who underwent either an open or robotic bilateral TAR from 1/2018 to 9/2020 were eligible for the study. Patients were stratified by age groups (≥ 60 years vs. < 60 years and < 60, 60-70, and ≥ 70) and by both age and operative approach. The rates of key postoperative outcomes and wound morbidity were compared between the various cohorts.

RESULTS

A total of 300 patients were included: 165 patients were ≥ 60 and 135 patients were < 60. Cohorts stratified by age were well-matched for important hernia factors: defect size (p = 0.31), BMI ≥ 30 (p = 0.46), OR time (p = 0.25), percent open TAR (p = 0.42), diabetes (p = 0.45) and history of prior surgical site infection (p = 0.40). The older cohort had significantly higher rates of coronary artery disease, hypertension, and COPD. On univariate analysis, cohorts stratified by age had similar rates of key postoperative and wound complications including in-hospital complications (p = 0.62), length of stay (p = 0.47), readmissions (p = 0.66), and surgical site occurrences (p = 0.68). Additionally, cohorts stratified by both age and operative approach also had similar outcomes. Multivariate analysis showed that chronological age was not independently associated with surgical site occurrences (p = 0.22), readmissions (p = 0.99), in-hospital complications (p = 0.15), or severe complications (p = 0.79).

CONCLUSION

Open and robotic TARs can be safely performed in older adults and chronological age alone is a poor predictor of patient morbidity following TAR. Further investigation of alternative preoperative screening tools that do not rely solely on age are needed to better optimize surgical outcomes in older adults following TAR.

"Delayed-Immediate" Hernia Repairs in Infected Wounds: Clinical and Economic Outcomes

BACKGROUND

Wound class in hernia repairs impacts surgical technique and outcomes. Hernia recurrence and complications are high when dirty wounds are treated in one stage. We hypothesize patients who undergo intentionally staged repairs are less likely to have adverse outcomes and associated costs.

METHODS

Patients were identified by retrospective chart review. Patient characteristics and outcome variables were collected. An economic analysis of cost variables was performed using medical records and published meta-analyses.

RESULTS

There were 8 patients in the staged repairs group and 10 patients in the control group. Length of stay was 14.9 days (±8.8), and 8.7 days (±6.4), respectively. Rate of hernia recurrence within 1 year was 14.3% and 37.5%. Rate of mesh infection at 30 days was 0% and 10%. Compared to controls, delayed-immediate repairs had a nearly 2-fold index surgical cost.

DISCUSSION

Although there is an increased cost associated with delayed-immediate repairs, this cost may be offset by the decreased infection, seroma, dehiscence, enterocutaneous fistula formation, and hernia recurrence rate that necessitates future interventions. Further data collection is required to determine if clinical and economic benefit is seen long-term.

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.

A Suture-less Underlay Ventral Herniorrhaphy Technique for High-Risk Complex Abdominal Wall Reconstruction

INTRODUCTION

Many factors increase the complexity of abdominal wall reconstruction including attenuated fascia, loss-of-domain, prior hernia surgeries, multiple fascial defects, enterocutaneous fistulas, and mesh infections. We describe our experience of using a suture-less mesh fixation underlay ventral herniorrhaphy technique to combat such issues in high-risk ventral hernia repair.

METHODS

This is a prospective-observational study. Patients from 2019 onward undergoing emergent or elective cases were included. The technique: A large porcine acellular-dermal-matrix (ADM) alone or sutured to a light-weight, macroporous polypropylene mesh is created and placed with ADM facing the bowel. Fibrin glue is sprayed over the mesh, fascia and skin closed. An abdominal binder is placed pre-extubation and left undisturbed for 5 postoperative days.

RESULTS

Of 34 included patients, the average demographic was a Caucasian (62.9%) female (65.7%), with class-I or greater obesity (76.5%), hypertension (74.3%), dyslipidemia (48.6%), non-skin malignancy (40.0%), type II diabetes mellitus (34.3%), a ventral hernia working group class of III-IV (55.9%), a mean of 3 ± 2.2 prior surgeries, and mean fascial defect size of 12.3 x 13.5cm. Five were prior solid-organ transplant recipients. Four patients underwent simultaneous tumor extirpations and herniorrhaphy. Five cases (14.7%) were emergent. Removal of prior mesh was performed in 48.5% of cases-seven had infected mesh. Median length of stay was 7 days, with 141 days median follow-up time. Fifteen patients (44.1%) developed a complication. Hernia-specific complications were limited to healing problems. There were no recurrences.

CONCLUSION

This technique is easy and safe to employ in patients requiring high-risk complex abdominal reconstructions with minimal hernia-specific complications.

Clinical outcomes of open abdominal wall reconstruction with the use of a polypropylene reinforced tissue matrix: a multicenter retrospective study

Objective

To assess mesh behaviour and clinical outcomes of open complex abdominal wall reconstruction (CAWR) with the use of a polypropylene reinforced tissue matrix.

Methods

A multicenter retrospective study of adult patients who underwent open CAWR with the use of a permanent polypropylene reinforced tissue matrix (OviTex^®) between June 2019 and January 2021.

Results

Fifty-five consecutive patients from four hospitals in the Netherlands were analysed; 46 patients with a ventral hernia and 9 patients with an open abdomen. Most patients with a ventral hernia had one or more complicating comorbidities (91.3%) and one or more complicating hernia characteristics (95.7%). Most procedures were performed in a (clean) contaminated surgical field (69.6% CDC 2–4; 41.3% CDC 3–4). All nine patients with an open abdomen underwent semi-emergent surgery. Twelve out of 46 patients with a ventral hernia (26.1%) and 4 of 9 patients with an open abdomen (44.4%) developed a postoperative surgical site infection that made direct contact with the mesh as confirmed on computed tomography (CT), suspicious of mesh infection. No patient needed mesh explantation for persistent infection of the mesh. During a median follow-up of 13 months, 4 of 46 ventral hernia patients (8.7%) developed a CT confirmed hernia recurrence.

Conclusion

Polypropylene reinforced tissue matrix can withstand infectious complications and provides acceptable mid-term recurrence rates in this retrospective study on open complex abdominal wall reconstructions. Longer follow-up data from prospective studies are required to determine further risk of hernia recurrence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-022-02604-y.