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Ahmed U, Rosenberg J, Baker JJ. Chronic pain and foreign body sensation based on mesh placement in primary ventral hernia repair: a systematic review highlighting the evidence gap and a call to action. Langenbecks Arch Surg 2025; 410:132. [PMID: 40257596 PMCID: PMC12011891 DOI: 10.1007/s00423-025-03671-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2025] [Accepted: 03/10/2025] [Indexed: 04/22/2025]
Abstract
PURPOSE This systematic review aimed to investigate differences in chronic pain and foreign body sensation based on mesh placement, with recurrence as a secondary outcome. METHODS The review was registered in PROSPERO (ID: CRD42024592114), and searches were conducted in MEDLINE (PubMed), Embase Ovid, and Cochrane CENTRAL on October 3rd, 2024. Studies were included if they compared mesh placements, categorized as onlay, retromuscular, preperitoneal, or intraperitoneal onlay mesh (IPOM), in primary ventral hernia repairs in adults. Chronic pain (≥ 6 months post-surgery) and foreign body sensation were the primary outcomes. Randomized controlled trials (RCTs) and cohort studies were included, while incisional hernias alone and animal studies were excluded. Risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and Cochrane Risk of Bias 2 (RoB2) tool for RCTs. Due to significant heterogeneity, a meta-analysis was not feasible, and a narrative synthesis was provided. RESULTS A total of 6,562 records were screened, of which nine cohort studies and one RCT were included. Studies were heterogeneous and many did not aim to assess chronic pain as the primary outcome. Two studies reported significantly lower chronic pain rates with retromuscular mesh placement, but data pooling was not possible. Foreign body sensation could not be assessed because the only study reporting on this did not have extractable data. CONCLUSION Currently, there is insufficient evidence to favor one mesh placement over another for chronic pain or foreign body sensation. While crude rates suggest that retromuscular and preperitoneal placements may result in less chronic pain than onlay and IPOM, the evidence remains very uncertain due to significant clinical and methodological heterogeneity. Further research is warranted.
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Affiliation(s)
- Usamah Ahmed
- Center for Perioperative Optimization, Department of Surgery, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, Herlev, DK-2730, Denmark.
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, Herlev, DK-2730, Denmark
| | - Jason Joe Baker
- Center for Perioperative Optimization, Department of Surgery, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, Herlev, DK-2730, Denmark
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Messer N, Miller BT, Beffa LRA, Petro CC, de Figueiredo SMP, Fafaj A, Ma J, Ellis RC, Maskal SM, Rosen MJ, Prabhu AS. Outcomes of posterior sheath supplementation with Vicryl mesh in TAR-a single-center study. Hernia 2024; 28:905-911. [PMID: 38700607 DOI: 10.1007/s10029-024-03054-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/18/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION In the Transversus Abdominis Release (TAR) procedure, ideally, the posterior sheath is completely reapproximated to establish an interface isolating the polypropylene mesh from visceral contents. When primary closure of the posterior sheath is unachievable, Vicryl mesh is commonly used to supplement the posterior sheath closure and an uncoated polypropylene mesh is placed superficial to the Vicryl mesh. The long-term implications of utilizing Vicryl mesh as an antiadhesive barrier are poorly understood. In this study, we aimed to assess our outcomes when utilizing Vicryl mesh to supplement the posterior sheath defects when placed underneath polypropylene mesh in patients undergoing posterior component separation. METHODS Adult patients who underwent VHR with concurrent TAR procedure with a permanent synthetic mesh and posterior sheath supplementation with Vicryl mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and December 2022 were queried retrospectively from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term mesh-related complications, and pragmatic hernia recurrence. RESULTS 53 patients who underwent TAR procedure with posterior sheath supplementation using Vicryl mesh and had a minimum 12-month follow-up were identified. Of the 53 patients, 94.3% presented with recurrent hernias, 73.6% had a midline hernia, 7.5% had a flank hernia, and 18.9% had concurrent parastomal hernia. The mean hernia width was 24.9 cm (± 8.8 cm). No Vicryl mesh-related operative complications were identified in our study, with no instances of mesh erosion, fistulas, or interventions for small bowel obstruction. Skin necrosis requiring reoperations was observed in three patients (5.7%), leading to permanent mesh excision in two cases (3.8%) without intraabdominal visceral involvement. Throughout the 12-month follow-up, 23 incidences (43.4%) of surgical site occurrences (SSOs) and surgical site occurrences requiring procedural intervention (SSOPI) were documented. CONCLUSIONS Our findings suggest that posterior sheath supplementation with Vicryl mesh is a feasible approach to achieve posterior sheath closure in challenging abdominal wall reconstruction cases. Given the absence of notable mesh-related complications and a similar hernia recurrence rate to cases without posterior sheath supplementation, Vicryl mesh can be used to safely achieve posterior sheath closure in complex reconstructions with insufficient native tissue.
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Affiliation(s)
- N Messer
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
- Department of Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel -Aviv University, Tel Aviv, Israel.
| | - B T Miller
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - L R A Beffa
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - C C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - S M P de Figueiredo
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - A Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - J Ma
- The Abdominal Core Health Quality Collaborative, Columbus, USA
| | - R C Ellis
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - S M Maskal
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - M J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - A S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Keric N, Campbell A. Meshing around: high-risk hernias and infected mesh. Trauma Surg Acute Care Open 2024; 9:e001379. [PMID: 38646030 PMCID: PMC11029232 DOI: 10.1136/tsaco-2024-001379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Open laparotomy carries a risk up to 20% for an incisional hernia, making repair one of the most common operations performed by general surgeons in the USA. Despite a multitude of mesh appliances and techniques, no size fits all, and there is continued debate on what is the best mesh type, especially in high-risk patients with contaminated hernias. Infected mesh carries a significant burden to the patient, the surgeon and overall healthcare costs with medical legal implications. A stepwise approach that involves optimization of patient comorbidities, patient selective choice of mesh and technique is imperative in mitigating outcomes and recurrence rates. This review will focus on the avoidance of mesh infection and the selection of mesh in patients with contaminated wounds.
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Affiliation(s)
- Natasha Keric
- Surgery, The University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
- Surgery, Banner—University Medical Center Phoenix, Phoenix, Arizona, USA
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