Open intraperitoneal versus retromuscular mesh repair for umbilical hernias less than 3cm diameter

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.

Parietex™ Composite Ventral Patch for primary and incisional hernia repair

BACKGROUNDS

Ventral hernia repair with a preformed device is a frequent intervention, but few reports exist with Parietex™ Composite Ventral Patch. The aim was to evaluate the results of this mesh with the open intraperitoneal onlay mesh (open IPOM) technique.

METHODS

Observational retrospective single institution study of all consecutive patients intervened for ventral or incisional hernia with a diameter inferior to 4 cm, from January 2013 to June 2020. The surgical repair was performed according to the open IPOM technique with Parietex™ Composite Ventral Patch.

RESULTS

A total of 146 patients were intervened: 61.6% with umbilical hernias, 8.2% with epigastric hernias, 26.7% with trocar incisional hernias, and 3.4% with other incisional hernias. The global recurrence rate was 7.5% (11/146). Specifically, it was 7.8% in umbilical hernias, 0% in epigastric hernias, 7.7% in trocar incisional hernias and 20% (1/5) in other incisional hernias. The median time for recurrence was 14 months (IQR: 4.4-18.7). The median indirect follow-up was 36.9 months (IQR: 27.2-49.6), and the median presential follow-up was 17.4 months (IQR: 6.5-27.3).

CONCLUSION

The open IPOM technique with a preformed patch offered satisfactory results for the treatment of ventral and incisional hernias.

Ventral Hernia Repair Using Ventralex® ST Patch: A Single-Center Study of Clinical Outcomes and Complications

Background

Ventralex® ST (Bard Davol Inc, Warwick, RI) patch is a composite self-expanding and non-absorbable mesh used to reinforce ventral hernia repair. This study was conducted to assess the efficacy, post-operative clinical outcomes, the duration of operation, and complications deciding the post-operative duration/need of hospitalization in patients of small ventral hernia after their open surgical repair using Ventralex ST hernia patch.

Materials and methods

We included 36 patients diagnosed with a small (<2 cm defect size) ventral hernia who underwent open mesh repair following strict surgical methodology using Ventralex® ST hernia patch between September 2018 and April 2020. It was a prospective observational study. Clinically relevant characteristics, along with operative and post-operative data collected through direct interview, clinical examination, and a pretested proforma, were analyzed prospectively.

Results

Thirty-four patients (94.5%) were observed to have an operative time of fewer than 60 minutes, with an average duration of 30-40 minutes. Thirty-one patients (86%) were discharged within 48 hours of surgery, out of which 17 patients (47.2%) were discharged within 24 hours of surgery and 14 patients (38.8%) within 48 hours. Only five patients (13.88%) had a prolonged hospital stay for more than 48 hours due to post-operative complications. Three patients (8.33%) acquired post-surgical wound infection, whereas two (5.55%) developed seroma. Nevertheless, just one patient (2.7%) reportedly developed both infection and seroma after surgery. No cases of mesh infection or recurrences were noted.

Conclusion

This study demonstrates that open repair of small (<2 cm defect size) ventral hernia using the Ventralex® ST hernia patch can be an extremely safe and effective method. Furthermore, it has excellent clinical outcomes when meticulously used with an easily reproducible surgical technique, which requires less intra-operative time, has minimal post-operative complications and negligible recurrence rate, along with reduced post-op hospital stay (86% of patients being discharged within 48 hours).

Favourable outcomes after Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Non-Complex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-Analysis

OBJECTIVE

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

SUMMARY BACKGROUND DATA

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For non-complex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

METHODS

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

RESULTS

Ninety-three studies representing 12440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% (95%CI: 2.2-4.2%, n = 11049) after minimally 12 months and 4.1%, (95%CI: 2.9-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2-6.4%, n = 4891) and 5.5% (95%CI: 4.4-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair (OR: 0.27, 95%CI: 0.15-0.51, p < 0.001) and equal recurrence rates compared to intraperitoneal onlay (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, p = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03-3.14, p = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8-2.8%, n = 982), albeit based on non-randomized studies.

CONCLUSIONS

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except surgical site infection. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.

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

BACKGROUND

The aim of this study was to assess whether the respective values of open and laparoscopic intraperitoneal repairs of umbilical hernias are related to the European Hernia Society diameter of defects.

METHODS

This registry-based study compared the early and 2-year outcomes of 776 open versus 1,019 consecutive laparoscopic intraperitoneal repairs performed from 2011 to 2019.

RESULTS

Intraperitoneal mesh repair, either laparoscopic or open, was found to be a safe procedure at the 2-year follow-up. The incidence of reoperated bowel obstructions was 0.3%. Compared with the open group: (1) postoperative surgical site occurrences in small (<2 cm) or medium (2-4 cm) hernias (0.3% vs 2.4%; P = .041; 1.4% vs 5.9%; P = .0002); (2) recurrence rates in large (≥4 cm) umbilical hernias (0.0% vs 8.6%; P = .0195); and (3) cumulative reoperation rates (0.9% vs 2.2%; P = .021) were significantly better in the laparoscopic group. Conversely, the rate of early pain on day 1 and 1 month postsurgery was higher in the laparoscopic group, for all hernia sizes (P < .001). The rate of moderate or severe chronic pain at 2 years was significantly higher in the laparoscopic group (8.1% vs 2.4%; P = .049) for small hernias.

CONCLUSION

The respective benefit to drawback ratios for open versus laparoscopic intraperitoneal repairs were related to the European Hernia Society diameter of hernia defect. In medium-large hernias, the benefits of laparoscopic repair overrode its drawbacks. In small hernias, the low recurrence rate, reduced early and chronic pain, and better rate of ambulatory surgery suggest there is still a place for open repair.

Intraperitoneal Tension-free Repair of a Small Midline Ventral Abdominal Wall Hernia: Randomized Study with a Mean Follow-up of 3 Years

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients’ characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster ( P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Robotic intraperitoneal onlay versus totally extraperitoneal (TEP) retromuscular mesh ventral hernia repair: A propensity score matching analysis of short-term outcomes

BACKGROUND

Short-term outcomes of robotic intraperitoneal onlay mesh(rIPOM) versus robotic totally extraperitoneal retromuscular mesh(rTEP-RM) ventral hernia repair were compared.

METHODS

A retrospective review of prospectively collected data of patients was conducted. A one-to-one propensity score matching(PSM) analysis was performed to achieve two well-balanced groups in terms of preoperative variables. A univariate and multivariate analysis were conducted to determine factors influencing post-operative outcomes.

RESULTS

Of 291 rIPOM and rTEP-RM procedures, 68 patients were assigned to each group after PSM. Operative times were longer for the rTEP-RM group. Adhesiolysis was more frequently required in rIPOM. The rTEP-RM allowed for a greater mesh-to-defect ratio. The rate of overall perioperative complications, Clavien-Dindo grades, and surgical site events were higher for the rIPOM group than the rTEP-RM group. The Comprehensive Complication Index® morbidity scores were lower in favor of rTEP-RM group. Adhesiolysis, rIPOM, and craniocaudal defect size were predictors for post-operative complications.

CONCLUSION

Robotic TEP-RM repair has better early postoperative outcomes for ventral hernias, suggesting that it may be preferable over robotic IPOM repair. Further studies with longer follow-up are needed.

Open ventral hernia repair with a composite ventral patch - final results of a multicenter prospective study

Background

This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex™ Composite Ventral Patch (PCO-VP).

Methods

A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed.

Results

One hundred twenty-six subjects (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8 cm (0.4–4.0) were treated with PCO-VP. One hundred subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0–6.3%) within 24 months. Median Numeric Rating Scale pain scores improved from 2 [0–10] at baseline to 0 [0–3] at 1 month (P < 0.001) and remained low at 24 months 0 [0–6] (P < 0.001). 99% (102/103) of the patients were satisfied with their repair at 24 months postoperative.

Conclusions

The use of PCO-VP to repair primary umbilical and epigastric defects yielded a low recurrence rate, low postoperative and chronic pain, and high satisfaction ratings, confirming that PCO-VP is effective for small ventral hernia repair in the two-year term after implantation.

Trial registration

The study was registered publically at clinicaltrials.gov (NCT01848184 registered May 7, 2013).

A systematic methodological review of non-randomised interventional studies of elective ventral hernia repair: clear definitions and a standardised minimum dataset are needed

BACKGROUND

Ventral hernias (VHs) often recur after surgical repair and subsequent attempts at repair are especially challenging. Rigorous research to reduce recurrence is required but such studies must be well-designed and report representative and comprehensive outcomes.

OBJECTIVE

We aimed to assesses methodological quality of non-randomised interventional studies of VH repair by systematic review.

METHODS

We searched the indexed literature for non-randomised studies of interventions for VH repair, January 1995 to December 2017 inclusive. Each prospective study was coupled with a corresponding retrospective study using pre-specified criteria to provide matched, comparable groups. We applied a bespoke methodological tool for hernia trials by combining relevant items from existing published tools. Study introduction and rationale, design, participant inclusion criteria, reported outcomes, and statistical methods were assessed.

RESULTS

Fifty studies (17,608 patients) were identified: 25 prospective and 25 retrospective. Overall, prospective studies scored marginally higher than retrospective studies for methodological quality, median score 17 (IQR: 14-18) versus 15 (IQR 12-18), respectively. For the sub-categories investigated, prospective studies achieved higher median scores for their, 'introduction', 'study design' and 'participants'. Surprisingly, no study stated that a protocol had been written in advance. Only 18 (36%) studies defined a primary outcome, and only 2 studies (4%) described a power calculation. No study referenced a standardised definition for VH recurrence and detection methods for recurrence varied widely. Methodological quality did not improve with publication year or increasing journal impact factor.

CONCLUSION

Currently, non-randomised interventional studies of VH repair are methodologically poor. Clear outcome definitions and a standardised minimum dataset are needed.

Tentacle-shaped mesh for fixation-free repair of umbilical hernias

Purpose

Mesh fixation and broad overlap represent an open issue in umbilical hernia repair. A proprietary-designed implant with tentacle straps at its boundary has been developed to ensure a suture-free repair and a broader coverage of the abdominal wall. The study describes the results of umbilical hernia procedures carried out with the tentacle-shaped implant and the related surgical technique.

Methods

A proprietary tentacle-shaped flat mesh having a central body with integrated radiating arms at its edge was used to repair large umbilical hernias in 62 patients. The implant was placed in preperitoneal sublay. The friction of the straps, crossing the abdominal wall thanks to a special needle passer, was intended to assure adequate grip to hold the implant in place assuring a fixation-free procedure and broad overlap of the hernia defect.

Results

In a mean follow-up of 48 months (range 10–62 months), 4 seromas and 2 ischemia of the navel skin occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence has been reported.

Conclusions

The tentacle strap system of the prosthesis effectively ensured an easier implant placement avoiding the need for suturing the mesh. The arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences even in the long term.

Retrospective analysis of smaller than 3-cm umbilical hernia repair with the lightweight macroporous mesh

There is evidence that mesh repair for primary umbilical hernias results in fewer recurrences and similar wound complication rates compared to tissue repair. Various devices and surgical approaches are used in umbilical hernia repair. The ULTRAPRO PLUG (UPP) has been adopted for inguinal hernias and femoral hernias with excellent results. However, there are few reports on the use of UPP for umbilical hernia repair. Thus, the aim of this study was to evaluate efficacy and safety in the treatment of smaller than 3-cm umbilical hernias using the UPP.The medical records of 123 patients who underwent umbilical hernia repair using the UPP between October 2011 and September 2017 were reviewed. All patients were followed-up after 1 month and later in 2018. Demographics, surgical information, and immediate postoperative and long-term complications were assessed.Out of 123 patients, there were 37 male and 86 female patients with a mean age of 50.6 years. The median duration of hernia surgery was 20.5 min (range, 12-34), and 109 (88.6%) patients underwent day surgery. The median defect diameter was 1.4 cm (range, 0.5-3). No mortality or major complications occurred during the perioperative period. Long-term follow-up data were available for 107 (87.0%) patients. The median follow-up duration was 33 months (range, 5-76 months). Early postoperative complications included 1 case of seroma, 2 cases of fat liquefaction, and 1 case of superficial surgical site infection. During follow-up, there were 2 recurrences, 1 case of chronic mesh infection, and 2 patients with chronic postoperative pain.The ULTRAPRO PLUG offers a simple and quick means of repairing smaller than 3-cm umbilical hernias with lower recurrence rates and fewer postoperative complications.

A short term analysis of surgical management of umbilical and paraumbilical hernia

Objective

Umbilical hernia and paraumbilical hernia are ventral herniae that occur in infants and adults. According to current evidence, mesh repair is the treatment of choice to avoid recurrence. The aim of this study is to analyze the surgical methods, the types of meshes used, and their benefits.

Material and Methods

A retrospective analysis of patients diagnosed with umbilical hernia and paraumbilical hernia was performed. The patients' consent was obtained retrospectively. The various surgical techniques and different meshes used were analyzed. Forty-three patients were selected for the study. Of these, 23 patients underwent open mesh repair, 12 patients underwent laparoscopic intraperitoneal onlay mesh repair repair, and eight patients underwent open intraperitoneal onlay mesh repair repair. The duration of the surgery, mesh used, number of days of hospital stay, type of anesthesia, and postoperative complications were analyzed.

Results

Of the 43 patients, the patients who underwent open intraperitoneal onlay mesh repair had shorter postoperative hospital stays compared to other methods (median=1 day; range=1 to 2 days). The duration of surgery was longer for laparoscopic intraperitoneal onlay mesh repair and open mesh repair compared to the open intraperitoneal onlay mesh repair technique (p<0.05).

Conclusion

The open intraperitoneal onlay mesh repair technique had advantages over the other methods for small-defect umbilical hernia and paraumbilical hernia. The duration of surgery was long for laparoscopic intraperitoneal onlay mesh repair compared to open mesh repair and the open intraperitoneal onlay mesh repair technique. Postoperative complications were insignificant for all three methods. Another advantage of the open intraperitoneal onlay mesh repair technique was a shorter postoperative hospital stay.

Importance of mesh overlap on hernia recurrence after open umbilical hernia repair with bilayer prosthesis

BACKGROUND

importance of mesh overlap on recurrence after open umbilical hernia repair has been poorly studied.

METHODS

a retrospective cohort study was performed with patients who underwent open umbilical hernia repair with bilayer prosthesis between 2004 and 2015.

RESULTS

1538 patients were included. Fifty patients (3.3%) had a mesh overlap lower than 1 cm. After a mean follow-up of 4.1 years 53 patients (3.5%) developed a recurrence. Recurrence was associated with a mesh overlap smaller than 1 cm (10.2% vs. 3.3%, p = 0.010, OR = 3.3). In the logistic regression model an overlap smaller than 1 cm was not statistically associated with recurrence (OR = 2.5, p = 0.123). Female gender, postoperative complications and prosthesis size were associated with hernia recurrence.

CONCLUSIONS

mesh overlap seems to be an important factor for hernia recurrence. A mesh overlap of at least 1 cm should be used until more studies are performed about this issue.

Prospective Analysis of Epigastric, Umbilical, and Small Incisional Hernia Repair Using the Modified Kugel Oval Patch

The study was performed to determine the complication and recurrence rate using the modified Kugel oval patch for small ventral hernia repair. Another aim of the study was to find risk factors for recurrence in patients with this repair. Seventy-three patients underwent ventral hernia repair with the modified Kugel oval patch between April 2013 and February 2015. Prospective follow-up data (18 months postoperative) were collected and evaluated. A total of 58 primary (18 epigastric/40 umbilical) and 15 incisional ventral hernias were repaired with the modified Kugel oval patch (7.6/10.2 cm/8 x 12 cm). We found three patients suffered superficial wound infection and two participants got hernia recurrence. Placement of mesh was found to be a significant risk factor for hernia recurrence. Small ventral hernia repair using the modified Kugel oval patch is a novel and useful approach and we recommend placing the patch preperitoneally.

Long-term follow-up results of umbilical hernia repair

Introduction

Multiple suture techniques and various mesh repairs are used in open or laparoscopic umbilical hernia (UH) surgery.

Aim

To compare long-term follow-up results of UH repair in different hernia surgery groups and to identify risk factors for UH recurrence.

Material and methods

A retrospective analysis of 216 patients who underwent elective surgery for UH during a 10-year period was performed. The patients were divided into three groups according to surgery technique (suture, mesh and laparoscopic repair). Early and long-term follow-up results including hospital stay, postoperative general and wound complications, recurrence rate and postoperative patient complaints were reviewed. Risk factors for recurrence were also analyzed.

Results

One hundred and forty-six patients were operated on using suture repair, 52 using open mesh and 18 using laparoscopic repair technique. 77.8% of patients underwent long-term follow-up. The postoperative wound complication rate and long-term postoperative complaints were significantly higher in the open mesh repair group. The overall hernia recurrence rate was 13.1%. Only 2 (1.7%) patients with small hernias (< 2 cm) had a recurrence in the suture repair group. Logistic regression analysis showed that body mass index (BMI) > 30 kg/m², diabetes and wound infection were independent risk factors for umbilical hernia recurrence.

Conclusions

The overall umbilical hernia recurrence rate was 13.1%. Body mass index > 30 kg/m², diabetes and wound infection were independent risk factors for UH recurrence. According to our study results, laparoscopic medium and large umbilical hernia repair has slight advantages over open mesh repair concerning early postoperative complications, long-term postoperative pain and recurrence.

A multicenter prospective study of patients undergoing open ventral hernia repair with intraperitoneal positioning using the monofilament polyester composite ventral patch: interim results of the PANACEA study

Purpose

This study assessed the recurrence rate and other safety and efficacy parameters following ventral hernia repair with a polyester composite prosthesis (Parietex™ Composite Ventral Patch [PCO-VP]).

Patients and methods

A single-arm, multicenter prospective study of 126 patients undergoing open ventral hernia repair with the PCO-VP was performed. Patient outcomes were assessed at discharge and at 10 days, 1, 6, 12, and 24 months postoperative.

Results

All patients had hernioplasty for umbilical (n = 110, 87.3%) or epigastric hernia (n = 16, 12.7%). Mean hernia diameter was 1.8 ± 0.8 cm. Mean operative time was 36.2 ±15.6 minutes, with a mean mesh positioning time of 8.1 ± 3.4 minutes. Surgeons reported satisfaction with mesh ease of use in 95% of surgeries. The cumulative hernia recurrence rate at 1 year was 2.8% (3/106). Numeric Rating Scale (NRS) pain scores showed improvement from 2.1 ± 2.0 at preoperative baseline to 0.5 ± 0.7 at 1 month postoperative (P < 0.001), and this low pain level was maintained at 12 months postsurgery (P < 0.001). The mean global Carolina’s Comfort Scale^® (CCS) score improved postoperatively from 3.8 ± 6.2 at 1 month to 1.6 ± 3.5 at 6 months (P < 0.001). One patient was unsatisfied with the procedure.

Conclusion

This 1-year interim analysis using PCO-VP for primary umbilical and epigastric defects shows promising results in terms of mesh ease of use, postoperative pain, and patient satisfaction. Recurrence rate is low, but, as laparoscopic evaluation shows a need for patch repositioning in some cases, an accurate surgical technique remains of utmost importance.

Identifying Effectors of Outcomes in Patients with Large Umbilical Hernias

Quality of life (QOL) has become an important focus of hernia repair outcomes. This study aims to identify factors which lead to ideal outcomes (asymptomatic and without recurrence) in large umbilical hernias (defect size ≥9 cm2). Review of the prospective International Hernia Mesh Registry was performed. The Carolinas Comfort Scale was used to measure QOL at 1-, 6-, and 12-month follow-up. Demographics, operative details, complications, and QOL data were evaluated using standard statistical methods. Forty-four large umbilical hernia repairs were analyzed. Demographics included: average age 53.6 ± 12.0 and body mass index 34.9 ± 7.2 kg/m2. The mean defect size was 21.7 ± 16.9 cm2, and 72.7 per cent were performed laparoscopically. Complications included hematoma (2.3%), seroma (12.6%), and recurrence (9.1%). Follow-up and ideal outcomes were one month = 28.2 per cent, six months = 42.9 per cent, one year = 55.6 per cent. All patients who remained symptomatic at one and two years were significantly symptomatic before surgery. Symptomatic preoperative activity limitation was a significant predictor of nonideal outcomes at one year ( P = 0.02). Symptomatic preoperative pain was associated with nonideal outcomes at one year, though the difference was not statistically significant ( P = 0.06). Operative technique, mesh choice, and fixation technique did not impact recurrence or QOL. Repair of umbilical hernia with defects ≥9 cm2 had a surprising low rate of ideal outcomes (asymptomatic and no recurrence). All patients with nonideal long-term outcomes had preoperative pain and activity limitations. These data may suggest that umbilical hernia should be repaired when they are small and asymptomatic.

Sublay versus underlay in open ventral hernia repair

BACKGROUND

The ideal location for mesh placement in open ventral hernia repair (OVHR) remains under debate. Current trends lean toward underlay or sublay repair. We hypothesize that in patients undergoing OVHR, sublay versus underlay placement of mesh results in fewer surgical site infections (SSIs) and recurrences.

MATERIALS AND METHODS

A multi-institution database of all OVHRs performed from 2010 to 2011 was accessed. Patients with mesh placed in the sublay or underlay position and at least 1 mo of follow-up were included. Primary outcome was SSI. Secondary outcome was hernia recurrence. Multivariate analysis was performed using logistic regression for SSI and Cox regression for recurrence. Subgroup analysis of elective, midline ventral incisional hernias was also performed.

RESULTS

Of 447 patients, 139 (31.1%) had a sublay repair. The unadjusted analysis showed no difference in SSI and lower recurrence using sublay compared with underlay. On multivariate analysis, there was no difference in SSI using sublay compared with underlay (odds ratio 1.5, 95% confidence interval [CI] 0.8-2.8). Recurrence was less common with sublay (hazard ratio 0.4, 95% CI 0.2-0.8). On subgroup analysis of elective, midline incisional hernias only (n = 247), there were more SSIs with sublay compared with underlay repair (28.0% versus 15.1%, P = 0.018); however, there was no difference in major SSI (sublay 9.3% versus underlay 5.8%, P = 0.315). There were fewer recurrences using sublay repair compared with underlay repair (10.7% versus 25.0%, P = 0.010).

CONCLUSIONS

In this multi-center, risk-adjusted study, sublay repair was associated with fewer recurrences than underlay repair and no difference in SSI. Randomized controlled trials are warranted to validate these findings.

Remodeling of Noncrosslinked Acellular Dermal Matrices in a Rabbit Model of Ventral Hernia Repair

Background: Bioprostheses represent a significant advance in the abdominal wall reconstruction since they become degraded until their complete elimination in the recipient organism. This study examines remodeling in the host of three noncrosslinked porcine dermal collagen biomeshes: Strattice™ (St; LifeCell Corp.), XCM Biologic® Tissue Matrix (XCM; Synthes CMF) and Protexa® (Pr; Deco Med S.R.L.). Methods: Partial ventral hernia defects created in New Zealand White rabbits were repaired using the biomeshes that were placed in an inlay, preperitoneal position. At 14 and 90 days after implantation, explants were assessed in terms of their host tissue incorporation by morphological studies, collagen gene/protein expression (quantitative real-time PCR/immunofluorescence), macrophage response (immunohistochemistry) and biomechanical strength. Results: There were no cases of mortality or infection. Among our macroscopic findings, the mesh detachment detected in one third of the Pr implants at 90 days was of note. The host tissue response to all the biomeshes was similar at both time points, with a tendency observed for their encapsulation. There were no appreciable signs of mesh degradation. The extent of host tissue infiltration and collagenization was greater for St and Pr than for XCM. Macrophages were observed in zones of inflammation and tissue infiltration inside the mesh. XCM showed a greater macrophage response at 90 days (p < 0.05). Improved tensile strength was observed for St (p < 0.05) over Pr and unrepaired defects. Conclusions:St showed the best behavior, featuring good collagenization and tensile strength while also inducing a minimal foreign body reaction.

Current options in umbilical hernia repair in adult patients

Umbilical hernia is a rather common surgical problem. Elective repair after diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh can be placed through either an open or laparoscopic approach with good clinical results. Standard polypropylene mesh is suitable for the open onlay technique; however, composite meshes are required for laparoscopic repairs. Large seromas and surgical site infection are rather common complications that may result in recurrence. Obesity, ascites, and excessive weight gain following repair are obviously potential risk factors. Moreover, smoking may create a risk for recurrence.

Closure of small and medium size umbilical hernias with the Proceed Ventral Patch in obese patients: a single center experience

Obesity is a risk factor for the development of umbilical hernia. Open hernia closure could be challenging in obese patients leading to high rates of recurrence. The aim of this study was to investigate the effectiveness and safety of hernia patches in the management of obese patients with umbilical hernias. All the patients included in this study were managed in the department of surgery of a primary care hospital in Germany. The data of patients undergoing umbilical hernia repair within a two-year period was retrospectively reviewed. Patients managed with the PVP were included for analysis. 24 obese patients were analyzed. Small and medium size patches were used in 15 and 9 patients respectively. The median duration of surgery was 40 min and the median length of hospital stay was 4d. The mean length of follow-up was 12 ± 9 months (range: 6–30 months). The rate of recurrence was 4.1% and the rate of complication was 8.3%. Obese patients presenting with small and medium size umbilical hernias could be safely and effectively managed with prosthetic patches like the Proceed Ventral Patch. However, the limited overlap zone following hernia closure with such a patch can be an issue.

Outcome of sublay mesh repair in non-complicated umbilical hernia with liver cirrhosis and ascites

BACKGROUND

Umbilical hernia repair is often accompanied by complications in patients with liver cirrhosis and ascites. It appears that the early elective repair of umbilical hernias in these patients is safer and can be considered for selected patients. The objective of this study is to evaluate the feasibility, safety, complications and technical aspects of sublay mesh repair of umbilical hernia in cirrhotic patients with ascites.

METHODS

Between October 2010 and April 2013, 70 patients with non-complicated umbilical hernia, liver cirrhosis and ascites were enrolled in this study. All patients underwent sublay mesh repair. Demographic data, preoperative variables, peri-operative course, and postoperative complications were recorded and analyzed.

RESULTS

A total of 38 women and 32 men underwent operation at an average age 51.24 years. The patients mean MELD score was 18 (range 12-25). The mean operative time was 67.45 min and the average hospital stay was 3.8 days. 2 patients had wound infection, 3 patients developed seroma and 1 patient had an ascitic fistula. Recurrence occurred in 1 (1.4%) patient and no mortality related to the procedure.

CONCLUSION

elective sublay umbilical hernia mesh repair is a safe approach and feasible technique in selected non-complicated cirrhotic patients with ascites.

Repair of umbilical and epigastric hernias

Umbilical and epigastric hernias are primary midline defects that are present in up to 50% of the population. In the United States, only about 1% of the population carries this specific diagnosis, and only about 11% of these are repaired. Repair is aimed at symptoms relief or prevention, and the patient's goals and expectations should be explicitly identified and aligned with the health care team. This article details some relevant and interesting anatomic issues, reviews existing data, and highlights some common and important surgical techniques. Emphasis is placed on a patient-centered approach to the repair of umbilical and epigastric hernias.

A Collective Review on Mesh-Based Repair of Umbilical and Epigastric Hernias

In accordance with the tension-free principles for other hernias, umbilical and epigastric hernia repair should probably be mesh-based. The number of randomized studies is increasing, most of them showing significantly less recurrences with the use of a mesh. Different devices are available and are applicable by several approaches. The objective of this review was to evaluate recent literature for the different types of mesh for umbilical and epigastric hernia repair and recurrences after mesh repair. A multi-database search was conducted to reveal relevant studies since 2001 reporting mesh-based repair of primary umbilical/epigastric hernia and their outcomes in adult patients. A total of 20 studies were included, 15 of them solely involved umbilical hernias, whereas the remaining studies included epigastric hernias as well. A median of 124 patients (range, 17-384) was investigated per study. Three quarters of the included studies had a follow-up of at least 2 years. Six studies described the results of laparoscopic approach, of which one reported a recurrence rate of 2.7 %; in the remaining studies, no recurrences occurred. Two comparative studies reported a lower incidence of complications and postoperative pain after laparoscopic repair compared to open repair. Seventeen studies reported results of open techniques, of which seven studies showed no recurrence. Other studies reported recurrence rates up to 3.1 %. A wide range of complication rates were reported (0-33 %). This collective review showed acceptable recurrence rates for mesh-based umbilical and epigastric hernia repair. A wide range of devices was investigated. A tendency toward more complications after laparoscopic repair was found compared to open repair.

Infected large pore meshes may be salvaged by topical negative pressure therapy

PURPOSE

To evaluate the efficacy of negative pressure therapy for superficial and deep mesh infections after ventral and incisional hernia repair by a prospective monocentric observational study.

METHODS

During a 6-year period, 724 consecutive open ventral and incisional hernia repairs were performed. Pre- and intraoperative data as well as postoperative complications were prospectively recorded. In case of wound infection, negative pressure therapy (NPT) was our primary treatment.

RESULTS

Sixty-three patients (8.7 %) were treated using negative pressure therapy after primary ventral and incisional hernia repair. Infectious complications needing NPT occurred in 54 patients in the retromuscular group (54/523; 10.3 %), none when laparoscopically treated and in 9 patients (9/143; 6.3 %) treated by an open intraperitoneal mesh technique. Considering outcome, all meshes were completely salvaged in the retromuscular mesh group after a median of 5 dressing changes (range, 2-9), while in the intraperitoneal mesh, group 3 meshes needed complete (n = 2) or partial (n = 1) excision. Mean duration to complete wound closure was 44 days (range, 26-63 days).

CONCLUSION

NPT is a useful adjunct for salvage of deep infected meshes, particularly when large pore monofilament mesh is used.

Repair of small and medium size ventral hernias with a Proceed Ventral Patch: a single center retrospective analysis

PURPOSE

Ventral hernias are common surgical targets. The Bard(®) Ventralex™ Hernia Patch was introduced for the repair of such hernias in the early 2000s. Ethicon (Johnson & Johnson) introduced the Proceed™ Ventral Patch (PVP™) in the late 2000s for the same indication. The effectiveness and safety of the Bard(®) Ventralex™ Hernia Patch has been proven in a series of studies. There are no medical studies on the PVP™ in humans. This study examines the effectiveness and safety of PVP™ in the closure of ventral hernias.

METHOD

A single center retrospective analysis of patients' data was conducted. Fifty-seven patients with small and medium size ventral hernias were treated with patches in the period between May 2009 and December 2010. The charts of these patients were reviewed. Demographic data, diagnosis at surgery, duration of surgery, length of hospital stay, postoperative complications and recurrence were recorded.

RESULTS

Fifty-seven patients were analyzed including 21 females and 36 males with a mean age of 56.7 years. The diagnosis at surgery included 36 cases of umbilical hernia, eight cases of epigastric hernia, seven incision hernias and six recurrent umbilical hernias. The mean duration of surgery was 30.7 min, and the mean length of hospital stay was 3.3 days. Four postoperative complications (7.1 %) and one case of hernia recurrence (1.7 %) were recorded.

CONCLUSION

Ventral hernia closure with PVP™ is safe and effective. The rates of complication and recurrence are comparable to those of the Bard(®) Ventralex™ Hernia Patch.