Prospective, multi-institutional surgical and quality-of-life outcomes comparison of heavyweight, midweight, and lightweight mesh in open ventral hernia repair

Heavyweight versus non-heavyweight mesh in ventral hernia repair: a systematic review and meta-analysis

PURPOSE

There is considerable variability among surgeons regarding the type of mesh used in ventral hernia repair. There has been an increasing incidence of mesh fractures with lightweight (LW) and mediumweight (MW) meshes. However, HW mesh has been associated with a greater foreign body sensation and chronic pain. This meta-analysis aims to compare the outcomes of HW and non-heavyweight (NHW) meshes in ventral hernia repair.

METHODS

We systematically reviewed the PubMed, Embase, Cochrane, and Scopus databases to identify studies comparing HW with NHW meshes in hernia repair. Outcomes analyzed included hernia recurrence, seroma, hematoma, foreign body sensation, postoperative pain, and wound infection. We performed two subgroup analyses focusing on randomized controlled trials and open retromuscular repairs. Statistical analysis was performed using RevMan 5.4.

RESULTS

We screened 1704 studies. Nine studies were finally included in this meta-analysis and comprised 3001 patients from 4 RCTs and 5 non-randomized. The majority of patients (57.1%) underwent open retromuscular repair. HW mesh was significantly associated with increased in foreign body sensation (OR 3.71; 95% CI 1.40-9.84; p = 0.008), but there was no difference in other outcomes. In RCTs analysis, there was no difference between meshes. In open retromuscular repairs, HW mesh was associated with more seromas (OR 1.48; 95% CI 1.01-2.17; p = 0.05).

CONCLUSION

Our study found that HW mesh was associated with more foreign body sensation. Also, open retromuscular repairs analysis showed that HW was associated with more seromas. Further randomized studies are needed to understand better the role of HW mesh in ventral hernia repair.

Comparison of Different Weight Meshes in Ventral/Incisional Hernia Repair, the Outcomes of Systematic Review and Meta-analysis

BACKGROUND

The use of mesh is not without complications. Decreasing the mesh weight with the light-weight (LW) mesh may improve tissue growth and diminish mesh-related complications, yet, clinically, there are conflicting results regarding the influence of different weight meshes in ventral/incisional hernia repair. The aim of the present study is to compare the outcomes of different weight meshes for ventral/incisional hernia repair.

METHODS

The major databases (PubMed, Embase, Springer, and Cochrane Library) were searched, and all studies were published through January 1, 2022, using the keywords "heavy weight" "light weight" "mesh" "ventral hernia" "incisional hernia". All relevant articles and reference lists in these original studies were also obtained from the above databases.

RESULTS

Eight trials (4 randomized controlled trials, 3 prospective studies, and 1 retrospective study) containing 1844 patients were included in the present meta-analysis. The pooled results showed that there was a significantly more rate of foreign body perception in the heavy-weight mesh group compared with the LW mesh group (odds ratio = 5.02, 95% CI: 1.05, 24.06). There was no significant difference concerning hernia recurrence, seroma, hematoma, surgical site infection, reoperation rate, chronic pain, quality of life, and hospital stay among different weight mesh groups.

CONCLUSION

Different weight meshes showed similar clinical results in ventral/incisional hernia repair, except that, perception of foreign body was reported more frequently in the heavy-weight mesh group as compared with the LW mesh group. However, the long-term hernia recurrence with different weights of meshes needs to be reevaluated considering the relative short-term follow-up in these studies.

Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement outcomes over 18 years and 1,842 patients

BACKGROUND

This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications.

METHODS

Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date.

RESULTS

Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m²; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm²; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036).

CONCLUSION

Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results.

Observational study of complex abdominal wall reconstruction using porcine dermal matrix: How have outcomes changed over 14 years?

BACKGROUND

Our center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction.

METHODS

Prospective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008-2014) and Recent (2015-2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed.

RESULTS

Comparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm²; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6-13] vs 7 [6-9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively. Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16-5.98; P = .020), panniculectomy (2.63, 1.21-5.73; P = .014), and anterior component separation (5.1, 1.98-12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032).

CONCLUSION

Porcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate.

Reoperation for Recurrence is Affected by Type of Mesh in Laparoscopic Ventral Hernia Repair: A Nationwide Cohort Study

OBJECTIVE

To compare the reoperation rate for recurrence between different mesh types in laparoscopic ventral hernia repair.

SUMMARY OF BACKGROUND DATA

Ventral hernia repair has improved over the last decades. Nevertheless, recurrence rates are still high, and one type of mesh was recently found to increase it even more.

METHODS

A nationwide cohort study based on prospectively collected data from the Danish Ventral Hernia Database. We included adult patients that had undergone a laparoscopic ventral hernia repair for either an incisional or a primary hernia. The primary and incisional hernias were analyzed in separate cohorts. The mesh-group with the lowest reoperation for recurrence curve was used as the reference. The outcome was reoperation for recurrence.

RESULTS

Study population comprised 2874 patients with primary hernias and 2726 with incisional hernias. For primary hernias, Physiomesh [HR = 3.45 (2.16-5.51)] and Proceed Surgical Mesh [HR = 2.53 (1.35-4.75)] had a significantly higher risk of reoperation for recurrence than DynaMesh-IPOM. For incisional hernias, Physiomesh [HR = 3.90 (1.80-8.46), Ventralex Hernia Patch (HR = 2.99 (1.13-7.93), Parietex Composite (incl. Optimized) (HR = 2.55 (1.17-5.55), and Proceed Surgical Mesh (HR = 2.63 (1.11-6.20)] all had a significantly higher risk of reoperation for recurrence than Ventralight ST Mesh.

CONCLUSION

For primary hernias, Physiomesh and Proceed Surgical Mesh had a significantly higher risk of reoperation for recurrence compared with DynaMesh-IPOM. For incisional hernias, the risk was significantly higher for Physiomesh, Parietex Composite, Ventralex Hernia Patch, and Proceed Surgical Mesh compared with Ventralight ST Mesh. This indicates that type of mesh may be associated with outcomes, and mesh choice could therefore depend on hernia type.

The early outcomes of complex abdominal wall reconstruction with polyvinylidene (PVDF) mesh in the setting of active infection: a prospective series

PURPOSE

The use of synthetic mesh to repair infected abdominal wall defects remains controversial. Polyvinylidene fluoride (PVDF) mesh was introduced in 2002 as an alternative to polypropylene, with the advantages of improved biostability, lowered bending stiffness, and minimum tissue response. This study aimed to evaluate the short-term outcomes of using PVDF mesh to treat infected abdominal wall defects in the elective setting.

METHODS

This prospective clinical trial started in 2016 and was designed to evaluate the short- and mid-term outcomes of 38 patients submitted to abdominal wall reconstruction in the setting of active mesh infection and/or enteric fistulas (AI) when compared to a group of 38 patients submitted to clean ventral hernia repairs (CC). Patients were submitted to single-staged repairs, using onlay PVDF mesh (DynaMesh®-CICAT) reinforcement to treat their defects.

RESULTS

Groups had comparable demographic characteristics. The AI group had more previous abdominal operations and required a longer operative and anesthesia time. At 30 days, surgical site occurrences were observed in 16 (42.1%) AI vs. 17 (44.7%) CC, p = 0.817; surgical site infection occurred in 4 (10.5%) AI vs. 6 (15.8%) CC, p = 0.497; and a higher number of procedural interventions were required in the CC group, 15.8 AI vs. 28.9% CC, p = 0.169. Both groups did not have chronic infections at 1 year of follow-up, and one hernia recurrence was observed in the AI group.

CONCLUSIONS

The use of PVDF mesh in the infected setting presented favorable results with a low incidence of wound infection.

Outcomes of posterior component separation with transversus abdominis release (TAR) in large and other complex ventral hernias: a single-surgeon experience

PURPOSE

Over the last years, great advances in the repair of abdominal wall hernias have dramatically improved patients' outcomes. Especially for large and other complex ventral hernias, the application of component separation techniques has been a landmark in their successful management. The aim of this study is to present our experience with the posterior component separation with transversus abdominis release (TAR) in patients with these demanding ventral hernias.

METHODS

A retrospective analysis of prospectively collected data of all patients who underwent elective ventral hernia repair with TAR between January 2016 and December 2019 was performed. Preoperative, intraoperative, and postoperative data were analyzed.

RESULTS

A total of 125 patients with large and other complex ventral hernias were included in the final analysis. More than 80% of patients had one or more comorbidities. Of all patients, 116 (92.8%) had a history of previous abdominal surgery, 27 (21.6%) had a history of SSI and nine (7.2%) had active fistulas. Postoperatively, SSOs were presented in 11 patients (8.8%), including three cases of SSI. Neither mesh infection occurred, nor mesh excision required. With a mean follow-up of 2.5 years, only one recurrence was observed.

CONCLUSIONS

With a wound complication rate of less than 9% and a recurrence rate of less than 1%, our results show that TAR is a reliable, safe and effective technique for the repair of massive and other complex ventral hernias. The combination of knowledge of the abdominal wall anatomy at a proficient level, proper training, and adoption of a strict prehabilitation program are considered prerequisites for the successful management of such demanding hernias.

Measuring quality of life in patients with abdominal wall hernias: a systematic review of available tools

INTRODUCTION

Abdominal wall herniation (AWH) is an increasing problem for patients, surgeons, and healthcare providers. Surgical-site specific outcomes, such as infection, recurrence, and mesh explantation, are improving; however, successful repair still exposes the patient to what is often a complex major operation aimed at improving quality of life. Quality-of-life (QOL) outcomes, such as aesthetics, pain, and physical and emotional functioning, are less often and less well reported. We reviewed QOL tools currently available to evaluate their suitability.

METHODS

A systematic review of the literature in compliance with PRISMA guidelines was performed between 1st January 1990 and 1st May 2019. English language studies using validated quality-of-life assessment tool, whereby outcomes using this tool could be assessed were included.

RESULTS

Heterogeneity in the QOL tool used for reporting outcome was evident throughout the articles reviewed. AWH disease-specific tools, hernia-specific tools, and generic tools were used throughout the literature with no obviously preferred or dominant method identified.

CONCLUSION

Despite increasing acknowledgement of the need to evaluate QOL in patients with AWH, no tool has become dominant in this field. Assessment, therefore, of the impact of certain interventions or techniques on quality of life remains difficult and will continue to do so until an adequate standardised outcome measurement tool is available.

Are laparoscopic and open ventral hernia repairs truly comparable?: A propensity-matched study in large ventral hernias

BACKGROUND

The merits of laparoscopic (LVHR) and open preperitoneal ventral hernia repair (OPPVHR) have been debated for more than 2 decades. Our aim was to determine peri-operative and long-term outcomes in large hernias.

METHODS

A prospective, institutional database at a tertiary hernia center was queried for patients undergoing LVHR and OPPVHR. One-to-one propensity score matching was performed for hernia defect size and follow-up.

RESULTS

Three hundred and fifty-two LVHR and OPPVHR patients were identified with defect sizes closely matched between laparoscopic (182.0 ± 110.0 cm²) and open repairs (178.3 ± 99.8 cm²), p = 0.64. LVHR and OPPVHR patients were comparable: mean age 57.2 ± 12.1 vs 56.6 ± 12.0 years (p = 0.52), BMI: 32.9 ± 6.6 vs 32.0 ± 7.4 kg/m² (p = 0.16), diabetes 19.0% vs 19.7% (p = 0.87), and smoking history 8.7% vs 23.0% (p < 0.001), respectively. OPPVHR had higher number of recurrent hernias (14.2% vs 44.9%, p < 0.001), longer operative time (168.1 ± 64.3 vs 186.7 ± 67.7 min, p = 0.006), and more components separation (0% vs 20.3%, p < 0.001). Mean mesh size was larger (p < 0.001) in the open group (634.4 ± 243.4 cm² vs 841.8 ± 277.6 cm²). The hernia recurrence rates were similar (10.8% vs 9.2%, p = 0.62), with average follow-up of 39.3 ± 32.5 vs 40.0 ± 35.0 months (p = 0.89). Length of stay was higher in the OVHR cohort (5.4 ± 3.0 vs 6.3 ± 3.6 days, p < 0.001), but 30-day readmission rates (4.0% vs 6.4%, p = 0.31) were similar. Overall wound infection rate (2.9% vs 8.4%, p = 0.03) was higher in the OPPVHR group, but the mesh infection rate was similar between LVHR (1.7%) and OPPVHR (0.6%) (p = 0.33). Postoperative pain (41.1% vs 41.4%, p = 0.95) and overall QOL based on the Carolinas Comfort Scale at 6 months (p = 0.73) and 5-years (p = 0.36) were similar.

CONCLUSION

Laparoscopic and open preperitoneal repair for large ventral hernias have equivalent hernia recurrence rates, postoperative pain, and QOL on long-term follow-up. Patients undergoing OPPVHR were more likely to be recurrent, complex, require components separation, and more likely to develop postoperative wound complications.

Two-year patient-related outcome measures (PROM) of primary ventral and incisional hernia repair using a novel three-dimensional composite polyester monofilament mesh: the SymCHro registry study

Purpose

This study examined patient-related outcome measures (PROMs) after repair of ventral primary or incisional hernias using Symbotex™ composite mesh (SCM), a novel three-dimensional collagen-coated monofilament polyester textile.

Methods

Pre-operative, peri-operative, and post-operative data were obtained from the French “Club Hernie” registry with 12- and 24-month follow-up.

Results

One-hundred consecutive patients (mean age 62.0 ± 13.7; 51% female) underwent repair of 105 hernias: primary (39/105, 37.1%, defect area 5.2 ± 5.6 cm²) and incisional (66/105, 62.9%, 31.9 ± 38.7.8 cm²). The mean BMI was 29.7 (± 5.6 kg/m²). American Society of Anesthesiologists classifications were I 39.4%, II 37.4% and III 23.2%. 75% had risk factors for healing and/or dissection. Of 38 primary repairs, 37 were completed laparoscopically (combined approach n = 1), and of 62 incisional hernia repairs, 40 were completed laparoscopically, and 20 by open repair (combined approach n = 2). Laparoscopic was quicker than open repair (36.2 ± 23.5 min vs. 67.4 ± 25.8, p < 0001). Before surgery, 86.3% of hernias were reported to cause discomfort/pain or dysesthesia. At 24 months (93 of 100 patients), 91 (97.8%) reported no lump and 81 (87.1%) no pain or discomfort. Of 91 patients, 86 (94.5%) rated their repair “good” or “excellent.” There were nine non-serious, surgeon-detected adverse events (ileus, n = 3; seroma, n = 6) and one hernia recurrence (6–12 months).

Conclusions

Compared to baseline, open and laparoscopic surgery improved PROMs 24 months after primary and incisional hernia repair. Minimal complications and recurrence support the long-term efficacy of SCM.

Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open

BACKGROUND

The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR.

STUDY DESIGN

The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes.

RESULTS

Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m², and defect area was 44.8 ± 88.1 cm². Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size.

CONCLUSIONS

Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.

Updates in Mesh and Biomaterials

Prior publications of the Surgical Clinics of North America have highlighted the technical challenges of abdominal wall reconstruction. This article provides an update on synthetic, biologic, and biosynthetic mesh research since the 2013 Surgical Clinics of North America hernia publication and highlights the future of mesh research. This update features research that has been conducted since the prior publication to guide surgeons to choose the best and most appropriate mesh for their patients.

First Year Preliminary Results on the Use of a Monofilament Polyester Mesh With a Collagen Barrier for Primary and Incisional Ventral Hernia Repair

Aim:

The SymCHro study objective is to assess patient outcomes and surgeon satisfaction following ventral hernia repair with a three-dimensional (3D) monofilament polyester mesh (Symbotex composite mesh) that contains an absorbable collagen barrier on 1 side to minimize tissue attachment.

Methods:

SymCHro is a multicenter observational study of 100 consecutive patients in the French Club Hernie registry who underwent primary and incisional ventral hernia repair with a Symbotex composite mesh. The primary objective is to assess recurrences and complications within 2 years of repair. This analysis reports 1-year results from the ongoing study.

Results:

A total of 105 hernias (37.1% primary, 62.9% incisional) in 100 patients were repaired by open or laparoscopic surgery. The patient follow-up rate at 1 year was 94%. A total of 6 (6.0%) low-grade seromas; 3 (3.0%) cases of low-grade transitory ileus; and 1 (1.0%) recurrence, which was asymptomatic but was repaired, occurred within 1-year follow-up. No serious adverse events were reported. All surgeons responded as satisfied with mesh flexibility and ease of insertion. Relative to baseline, patient pain reduced significantly at day 1 through month 3 postoperatively. At 1 year, 88.3% (83/94) patients assessed the hernia operation results as “good” or “excellent.”

Conclusion:

At this 1-year analysis, 94% of patients were followed up and experienced minimal pain and low complication rates, suggesting that Symbotex composite mesh provides an effective and safe repair for primary and incisional ventral hernias.