Are the relative benefits of open versus laparoscopic intraperitoneal mesh repair of umbilical hernias dependent on the diameter of the defect?

Minimally invasive umbilical hernia repair is safe for patients with liver dysfunction: A propensity-score-matched analysis of approach and outcomes using ACS-NSQIP

BACKGROUND

Umbilical hernias are highly prevalent in patients with liver dysfunction, ascites, and cirrhosis. This patient population carries significant perioperative risk and poses significant challenges because of their comorbidities. Literature suggests that elective repair of umbilical hernias can lead to better outcomes by reducing the risk of ascitic leak and compromised bowel. Medical optimization followed by open repair has been the standard approach; however, little is known about whether a laparoscopic approach may be equivalent or superior.

METHODS

We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021 for umbilical hernia repairs in patients with liver dysfunction, as defined per the aspartate aminotransferase to platelet ratio index ≥1. We compare operative outcomes for open and laparoscopic repair, adjusting for confounders using propensity score matching and stratifying by case acuity.

RESULTS

We identified 1,983 patients with liver dysfunction who underwent umbilical hernia repair. Most patients (86%) were operated via an open approach rather than laparoscopy. Operative outcomes between the laparoscopy and open group were comparable regarding mortality and serious complications. Notably, length of stay and need for blood transfusion intraoperatively or postoperatively were reduced in the laparoscopy group (P < .001). These findings remained significant after subgroup analysis with propensity matching stratified by elective and emergency case types.

CONCLUSION

Minimally invasive umbilical hernia repair in liver dysfunction is as safe and, in some metrics, superior to open technique. We found no difference in mortality although hospital stays and the need for blood transfusions were lower in the laparoscopy groups. Prospective randomized trials are needed to validate these findings further.

Open IPOMs for medium/large incisional ventral hernia repairs in the French Hernia Registry: factors associated with their use and mesh-related outcomes

PURPOSE

The use of open intra-peritoneal onlay mesh repairs (O-IPOMs) for treating medium/large incisional ventral hernias has come into question due to the development of minimally invasive and sublay procedures. This study aimed to identify factors that are associated with the use of O-IPOMs in France.

METHODS

We analysed prospectively collected data from the French Hernia Registry on incisional ventral hernia repairs (IVHR) for hernias ≥ 4 cm in width.

RESULTS

We obtained data for 2261 IVHR (from 11/09/2011 to 30/03/2020): 733 O-IPOMs and 1,528 other techniques. We found that the O-IPOMs were performed on patients with more patient-related risk factors compared with the other techniques. Specifically, there was a higher proportion of patients with ASA III/IV (40.47% vs. 28.02%; p < 0.00001) and at least one patient-related risk factor (66.17% vs. 58.51%; p = 0.0005). Of the 733 O-IPOMs, 195 used Ventrio ST™ (VST), the most commonly used mesh for such IPOMs in our database; the other 538 O-IPOMs used other meshes (OM). The VST subgroup had a higher proportion of patients with ASA III/IV (52.58% vs. 36.07%; p < 0.0001) and on anticoagulants (26.04% vs. 18.41%; p = 0.0229) compared with the OM subgroup; they also had a lower recurrence rate after 2 years (5.83% vs. 15.41%; p = 0.008). However, large (≥ 10 cm) or lateral defects were more common in the OM subgroup, and their mesh/defect area ratio was lower.

CONCLUSION

O-IPOMs were performed on patients with more comorbidities and/or complex incisional hernias compared with other techniques.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Suture versus open mesh repair for small umbilical hernia: Results of a propensity-matched cohort study

BACKGROUND

The objective was to compare the outcomes of open mesh repair versus suture repair for small (≤1 cm in diameter) umbilical hernia. The primary endpoint was the 30-day outcomes including pain, and secondary endpoints were the 2-year outcomes including recurrences and patient-reported outcomes.

METHODS

This propensity-matched, multicenter study was carried out on data collected prospectively in the Hernia-Club database between 2011 and 2021. A total of 590 mesh repairs and 590 suture repairs were propensity score matched (age, sex, body mass index) at a ratio of 1:1. Postoperative pain was assessed using the Verbal Rating Scale-4 and 0‒10 Numerical Rating Scale-11.

RESULTS

Mesh insertion was intraperitoneal in 331 patients (56.1%), extraperitoneal in 249 (42.2%), and onlay in 10 (1.7%). The rate of 30-day complications and Numerical Rating Scale-11 pain scores on postoperative days 8 and 30 were similar between the groups, including surgical site occurrences (2.2 vs 1.4% after suture repair). At 1 month, postoperative discomfort (sensation of something different from before) was significantly (P < .0001) more frequent after mesh repair, whereas the rate of relevant (moderate or severe) pain (mesh repair: 1.1% vs suture repair: 2.6%) and the distribution of Numerical Rating Scale-11 scores did not differ between the groups. At the 2-year follow-up, mesh repair patients had fewer reoperated recurrences (0.2% vs 1.7%; P = .035) and no more pain or discomfort than suture repair patients.

CONCLUSION

Both techniques are effective and safe. Mesh repair is likely to reduce the rate of recurrences. Concerns about postoperative pain and infection might not prevent the use of mesh in smallest umbilical hernias.