Application of bridging mesh repair in giant ventral incisional hernia

Achieving ideal abdominal wall reconstruction in giant ventral incisional hernia has been a challenging for surgeons. This study aimed to verify the safety and efficacy of bridging repair by comparing it with primary fascial closure (PFC) repair in the treatment of giant ventral incisional hernia. We retrospectively analyzed the clinical data of 92 patients with giant ventral incisional hernia who underwent mesh repair at our medical institution from January 1, 2014 to December 31, 2020. Patients were divided into 2 groups: the bridging repair group with 40 patients in whom repair was completed using the bridging technique and the PFC group with 52 patients in whom primary fascial closure was achieved and all patients underwent mesh reinforcement during the operation. The main outcome measures were recurrence rate and morbidity, especially intra-abdominal hypertension (IAH). Follow-up time of both groups lasted at least 24 months after surgery. After a median of 46 months and 65 months of follow-up, respectively, in the two groups, bridging repair did not increase the long-term recurrence rate (2.56%) in the larger defect area group compared to the PFC group (1.96%). There were no significant differences in perioperative morbidity, IAH, incidence of postoperative chronic pain, and sensory impairment of the abdominal wall between both groups. The application of bridging surgery in the treatment of complex giant ventral incisional hernias is safe and effective and does not significantly increase the postoperative recurrence rate.

Sarcopenia and body fat change as risk factors for radiologic incisional hernia following robotic nephrectomy

OBJECTIVE

To assess the effect of body muscle and fat metrics on the development of radiologic incisional hernia (IH) following robotic nephrectomy.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent robotic nephrectomy for kidney tumors between 2011 and 2017. All pre- and postoperative CTs were re-reviewed by experienced radiologists for detection of radiologic IH and calculation of the following metrics using Synapse 3D software: cross-sectional psoas muscle mass at the level of L3 and L4 as well as subcutaneous and visceral fat areas. Sarcopenia was defined as psoas muscle index below the lowest quartile. Cox proportional hazard model was constructed to examine the association between muscle and fat metrics and the risk of developing radiologic IH.

RESULTS

A total of 236 patients with a median (IQR) age of 64 (54-70) years were included in this study. In a median (IQR) follow-up of 23 (14-38) months, 62 (26%) patients developed radiologic IH. On Cox proportional hazard model, we were unable to detect an association between sarcopenia and risk of IH development. In terms of subcutaneous fat change from pre-op, both lower and higher values were associated with IH development (HR (95% CI) 2.1 (1.2-3.4), p = 0.01 and 2.4 (1.4-4.1), p < 0.01 for < Q1 and ≥ Q3, respectively). Similar trend was found for visceral fat area changes from pre-op with a HR of 2.8 for < Q1 and 1.8 for ≥ Q3.

CONCLUSION

Both excessive body fat gain and loss are associated with development of radiologic IH in patients undergoing robotic nephrectomy.

Incidence, Risk Factors, and Management of Incisional Hernias After Kidney Transplant: A 20-Year Single Center Experience

BACKGROUND

Incisional hernias (IH) constitute a complication after kidney transplant (KT). Patients may be particularly at risk because of comorbidities and immunosuppression. The study aim was to assess the incidence, risk factors, and treatment of IH in patients undergoing KT.

METHODS

This retrospective cohort study included consecutive patients who underwent KT between January 1998 and December 2018. Patient demographics, comorbidities, perioperative parameters, and IH repair characteristics were assessed. Postoperative outcomes included morbidity, mortality, need for reoperation, and length of stay (LOS). Patients who developed IH were compared with those who did not develop one.

RESULTS

Forty-seven patients (6.4%) developed an IH after a median delay of 14 months (IQR, 6-52 months) in 737 KTs. On uni- and multivariate analyses, body mass index (odds ratio [OR], 1.080; P = .020), pulmonary diseases (OR, 2.415; P = .012), postoperative lymphoceles (OR, 2.362; P = .018), and LOS (OR, 1.013; P = .044) were independent risk factors. Thirty-eight patients (81%) underwent operative IH repair, and 37 (97%) were treated with a mesh. The median LOS was 8 days (IQR, 6-11 days). Three patients (8%) developed surgical site infections, and 2 patients (5%) presented hematomas requiring surgical revision. After IH repair, 3 patients (8%) had a recurrence.

CONCLUSIONS

The incidence of IH after KT seems rather low. Overweight, pulmonary comorbidities, lymphoceles, and LOS were identified as independent risk factors. Strategies focusing on the modifiable patient-related risk factors and early detection and treatment of lymphoceles may help to decrease the risk of IH formation after KT.

Comparison of two fascial defect closure methods for laparoscopic incisional hernia repair

PURPOSE

Currently there is no consensus regarding the optimal surgical approach to an incisional hernia measuring less than 10 cm. Certain hernia features including defect size, intra-abdominal adhesions, and overlying scar/skin properties contribute to choosing an open versus a laparoscopic approach. This retrospective cohort study was designed to compare incisional hernia defects repaired with laparoscopic suture closure to a hybrid approach with open defect closure, both with laparoscopic intraperitoneal onlay mesh (IPOM) reinforcement.

METHODS

We identified 164 consecutive patients who underwent incisional hernia repair from two centers, North York General Hospital (NYGH) and Humber River Hospital (HRH) between 2015 and 2020. Patients were grouped by totally laparoscopic or hybrid fascial closure. Both techniques included laparoscopically placed intra-peritoneal mesh with 5 cm of overlap in all directions. Patients were analyzed by age, sex, body mass index (BMI), ASA class and hernia size. Primary outcomes included surgical site infection (SSI), other wound complications including seroma/hematoma, length of hospital stay, pain reported at follow-up appointment, and hernia recurrence.

RESULTS

Post-operative pain, surgical site infections and seromas did not differ between the totally laparoscopic and hybrid approach. The recurrence rates were 5.8% and 6.8% for the laparoscopic and hybrid group, respectively, which were not significantly different. The time to recurrence was 15 months (range 8-12) in the laparoscopic group and 7 months (range 6-36) in the hybrid group, also not significantly different. The hernia defect size and BMI were significantly higher in the hybrid group, without increased wound complications.

CONCLUSION

These results suggest that a hybrid approach to incisional ventral hernia repair with open defect closure is comparable to a totally laparoscopic closure. The hybrid technique can help facilitate fascial closure and resection of the hernia sac in patients with higher BMI and hernia defects up to 6 cm.

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.

The Risk of Incarceration During Nonoperative Management of Incisional Hernias: A Population-based Analysis of 30,998 Patients

OBJECTIVE

The aim of the study was to quantify the risk of incarceration of incisional hernias.

BACKGROUND

Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown.

METHODS

A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration.

RESULTS

Among 30,998 patients with an incisional hernia (mean age 58.1 ± 15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively.

CONCLUSIONS

Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.

Postoperative complications of colorectal cancer

Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.

Appendicitis in an incisional hernia sac following renal transplantation: A case report and brief review of the literature

Acute appendicitis is a surgical emergency. However, the presence of vermiform appendix in a hernial sac is rare. It is even rarer to find inflamed appendix in an hernial sac. The most common site is right groin hernia (Inguinal > Femoral). There is low incidence of an incisional hernia following renal transplantation, as compared to patients with laparotomy. Appendicitis in hernial sac masquerades clinical presentation of an incarcerated hernia. Computed tomography plays a pivotal role in early diagnosis, demonstrating a dilated appendix with wall thickening and peri-appendiceal fat stranding. Patients are managed with appendectomy. The management of appendiceal hernias without inflammation remains controversial, with few reported cases managed with hernia sac repair or appendectomy. In this report were described a case of appendicitis in an incisional hernia following renal transplantation which was managed with appendectomy.

Preventing incisional ventral hernias: important for patients but ignored by surgical specialities? A critical review

PURPOSE

Incisional ventral hernias (IHs) are a common complication across all surgical specialities requiring access to the abdomen, pelvis, and retroperitoneum. This public health issue continues to be widely ignored, resulting in appreciable morbidity and expenses. In this critical review, the issue is explored by an interdisciplinary group.

METHODS

A group of European surgeons encompassing representatives from abdominal wall, vascular, urological, gynecological, colorectal and hepato-pancreatico-biliary surgery have reviewed the occurrence of His in these disciplines.

RESULTS

Incisional hernias are a major public health issue with appreciable morbidity and cost implications. General surgeons are commonly called upon to repair IHs following an initial operation by others. Measures that may collectively reduce the frequency of IH across specialities include better planning and preparation (e.g. a fit patient, no time pressure, an experienced operator). A minimally invasive technique should be employed where appropriate. Our main recommendations in midline incisions include using the 'small bites' suture technique with a ≥ 4:1 suture-to-wound length, and adding prophylactic mesh augmentation in patients more likely to suffer herniation. For off-midline incisions, more research of this problem is essential.

CONCLUSION

Meticulous closure of the incision is significant for every patient. Raising awareness of the His is necessary in all surgical disciplines that work withing the abdomen or retroperitoneum. Across all specialties, surgeons should aim for a < 10% IH rate.

Management of Open Abdomen After Trauma Laparotomy: A Comparative Analysis of Dynamic Fascial Traction and Negative Pressure Wound Therapy Systems

BACKGROUND

Management of the post-traumatic open abdomen (OA) using negative pressure wound therapy (NPWT) alone is associated with low rates of primary fascial closure. The abdominal reapproximation anchor (ABRA) system exerts dynamic medial fascial traction and may work synergistically with NPWT to facilitate primary fascial closure.

METHODS

Patients with an OA following trauma laparotomy between 2009 and 2018 were identified from a prospectively maintained institutional database. Patients treated with ABRA in conjunction with NPWT (ABRA) versus NPWT alone (NPWT) were compared in terms of primary fascial closure rate, number of surgeries to closure, tracheostomy duration, length of stay and incidence of entero-atmospheric fistula. Multivariable linear regression was performed to identify predictors of tracheostomy duration.

RESULTS

We identified 48 patients [ABRA, 12 and NPWT, 36]. The ABRA group was significantly younger (25 vs. 37 years, p = 0.027) and included a lower proportion of males (58% vs. 89%, p = 0.032). Groups were similar with respect to the incidence of hollow viscus injury, injury severity score and abdominal abbreviated injury score. Compared to the NPWT group, the ABRA group had a significantly higher rate of primary fascial closure (100% vs. 28%, p < 0.001), fewer surgeries to abdominal closure (2 vs. 2.5, p = 0.023) and shorter duration of tracheostomy (15.5 vs. 36 days, p = 0.008). There were no differences in length of stay or incidence of entero-atmospheric fistula. On multivariable linear regression, ABRA placement was an independent predictor of shorter tracheostomy duration, after adjusting for covariates (β = - 0.294, p = 0.036).

CONCLUSION

For the post-traumatic OA, ABRA coupled with NPWT achieves a higher rate of primary fascial closure compared to NPWT alone, while requiring fewer surgeries and a shorter duration of tracheostomy.

Watchful Waiting for Ventral Hernias: A Longitudinal Study

Ventral hernias are a common clinical problem. Immediate repair is recommended for most ventral hernias despite significant recurrence rates. This practice may be related to a lack of understanding of the natural history of ventral hernias. The purpose of this study was to determine the natural history of ventral hernias and to determine if watchful waiting is an acceptable and safe option. Forty-one patients with ventral hernias were enrolled in a longitudinal cohort study of watchful waiting. Primary outcomes were functional impairment resulting from hernia disease as measured by the Activities Assessment Scale (AAS) and changes from baseline to two years in the physical and mental component score of the SF-36 Health Survey. Secondary outcomes included complications such as incarceration. Mixed-effects model for repeated measures and Student's t tests were used to evaluate scale performance. The mean age of enrollees was 64 years, and the mean hernia size was 239 cm2. Eleven patients were lost to follow-up, and seven patients died of other causes. All remaining patients were followed for two years. There was one incarceration during the follow-up period. There was no deterioration in the AAS score (baseline vs 24 months = 28 vs 25, P = 0.60). There was deterioration of the physical functioning dimension of the SF-36 (baseline vs 24 months = 40 vs 32, P < 0.01), but the mental functioning dimension was improved (45 vs 51; P = 0.01). Watchful waiting was a safe option for patients in this study with ventral hernias.

One-year outcome after repair of giant incisional hernia using synthetic mesh or full-thickness skin graft: a randomised controlled trial

Purpose

Repair of giant incisional hernia often requires complex surgery and the results of conventional methods using synthetic mesh as reinforcement are unsatisfactory, with high recurrence and complication rates. Our hypothesis was that full-thickness skin graft (FTSG) provides an alternative reinforcement material for giant incisional hernia repair and that outcome is improved. The aim of this study was to compare FTSG with conventional materials currently used as reinforcement in the repair of giant incisional hernia.

Methods

A prospective randomised controlled trial was conducted, comparing FTSG with synthetic mesh as reinforcement in the repair of giant (> 10 cm minimum width) incisional hernia. One-year follow-up included a blinded clinical examination by a surgeon and objective measurements of abdominal muscle strength using the Biodex-4 system.

Results

52 patients were enrolled in the study: 24 received FTSG and 28 synthetic mesh. Four recurrences (7.7%) were found at 1-year follow-up, two in each group. There were no significant differences regarding pain, patient satisfaction or aesthetic outcome between the groups. Strength in the abdominal wall was not generally improved in the study population and there was no significant difference between the groups.

Conclusion

The outcome of repair of giant incisional hernia using FTSG as reinforcement is comparable with repair using synthetic mesh. This suggests that FTSG may have a future place in giant incisional hernia repair.

Risk Factors for Surgical Complications in Ventral Hernia Repair

BACKGROUND

The aim of this study was to identify risk factors for an adverse event, i.e. early surgical complication, need for ICU care and readmission, following ventral hernia repair. Our hypothesis was that there is an association between an increased complication rate following ventral hernia repair and specific factors, including hernia size, BMI > 35, concomitant bowel surgery, ASA-class, age, gender and method of hernia repair.

METHODS

Data from a hernia database with prospectively entered data on 408 patients operated for ventral hernia between 2007 and 2014 at two Swedish university hospitals were analysed. A 3-month follow-up of complications, need for intensive care and readmission, was performed by reviewing the medical records.

RESULTS

Eighty-one of 408 patients (20%) had a registered complication. Fifty-eight (14%) of these were classed as Clavien I-IIIa, and in 19 cases a Clavien IIIb-IV complication was reported. Large hernia size was associated with increased risk for early complication. A Kendall Tau test analysis revealed a proportional relationship between hernia size and modified Clavien outcome class (p < 0.001). Morbid obesity, ASA-class, method, hernia recurrence, age and concomitant bowel surgery were not statistically significant predictors of adverse events.

CONCLUSIONS

Assessment of hernia aperture size is of great importance in the preoperative evaluation of ventral hernia patients to consider risk for post-operative complications. These results suggest a careful attitude when applying watchful waiting concepts and when postponing hernia surgery to achieve weight loss. A delaying attitude may result in increased risk of complications caused by increasing hernia size.

Delayed Incisional Hernia Following Minimally Invasive Trans-Psoas Lumbar Spine Surgery: Report of a Rare Complication and Management

Background

Lateral lumbar interbody fusion (LLIF) has proved to be a safe tool in the armamentarium of spine surgeons for a variety of lumbar disorders. However, it has some complications related to specific approaches. Incisional hernia following abdominal surgery and anterior spinal surgery is commonly described; however, it is extremely rare following LLIF, with only 1 case reported in short postoperative period. In this report we present the first case of delayed presentation of true incisional hernia following a LLIF procedure and highlight its presentation, mechanism, possible preventive measures, and management.

Methods

We report a 57-year-old lady who underwent L3-4 LLIF. She presented with vague pain in a healed scar area that had no swelling until two years postsurgery, when she developed a painful swelling. On examination, it appeared to be a herniation of abdominal contents.

Results

She underwent a laparoscopic hernia repair surgery. The muscular layers were found to be intact with an attenuated transversalis fascia layer. The repair was reinforced by polypropylene mesh. There was no recurrence at the 6-month follow-up.

Conclusions

Incisional hernia can occur following LLIF months to years following surgery and can have varied presentation. Tight external oblique closure should be performed because the transversalis fascia often cannot be repaired and the quality of a layered closure of the deep obliques is often disappointing. The treating surgeon should be aware of this complication and aggressively surveil for the warning signs, and patients should be counseled about this potential complication.

Vacuum-Assisted Abdominal Closure Is Safe and Effective: A Cohort Study in 74 Consecutive Patients

BACKGROUND

Vacuum-assisted closure (VAC) has, in many instances, become the treatment of choice in patients with abdominal catastrophes. This study describes the use and outcome of ABThera KCI® VAC in the Region Southern Denmark covering a population of approximately 1.202 mill inhabitants.

METHOD

A prospective multicenter study including all patients treated with VAC during an eleven-month period.

RESULTS

A total of 74 consecutive patients were included. Median age was 64.4 (9-89) years, 64% were men, and median body mass index was 25 (17-42). Duration of VAC treatment was median 4.5 (0-39) days with median 1 (0-16) dressing changes. Seventy per cent of the patients attended the intensive care unit. The 90-day mortality was 15%. A secondary closure of the fascia was obtained in 84% of the surviving patients. Only one patient developed an enteroatmospheric fistula. Patients with secondary closure were less likely to develop large hernias and had better self-evaluated physical health score (p < 0,05). No difference in mental health was found.

CONCLUSION

The abdominal VAC treatment in patients with abdominal catastrophes is safe and with a relative low complication rate. Whether it might be superior to conventional treatment with primary closure when possible has yet to be proven in a randomized study.

Incisional hernia in pediatric surgery - experience at a single UK tertiary centre

AIMS

Incisional hernia (IH) is a recognized complication of open and laparoscopic visceral surgery, with reported rates of 10-50% in adult surgical literature. There is a paucity of data relating to incisional hernias in children. The aim of our study was to analyze the incidence and treatment of IH in children.

METHODS

Retrospective review of all patients admitted for incisional hernia repair at a tertiary pediatric surgical centre in the UK more than a 7-year period was performed. Data collected included age at initial surgery, time to IH repair, and type of IH repair and postoperative complications.

RESULTS

Twenty one patients (14 male) underwent IH repair during the study period. The incidence of IH among children who had primary abdominal surgery in our institution less than the age of 6months was 2.3%. Median age at repair was 7.9months (range: 18days-5years). Median time from primary surgery to diagnosis of IH was 2months (range 0day-3years), with 81% (17/21) diagnosed within 1year of the preceding abdominal procedure. The most common pathology necessitating the primary operative procedure was necrotising enterocolitis (n=9) in babies of gestational age less than 30weeks. The highest rates of IH were noted in infants following closure of stoma (7.5%) and pyloromyotomy (2.52%). Primary closure was undertaken in all cases. Two children had recurrence of IH, one of which underwent surgical repair.

CONCLUSIONS

Incidence of IH in children is low but significant. IH was most commonly diagnosed following closure of stoma for NEC in this study.

Transversus Abdominis Release for Abdominal Wall Reconstruction: Early Experience with a Novel Technique

BACKGROUND

Ventral hernias are common sequelae of abdominal surgery. Recently, transversus abdominis release has emerged as a viable option for large or recurrent ventral hernias. Our objective was to determine the outcomes of posterior component separation via transversus abdominis release for the treatment of abdominal wall hernias in the first series of patients at one institution.

METHODS

We performed a retrospective review of a prospectively maintained database of open ventral hernia repair patients to identify patients who underwent posterior component separation via transversus abdominis release at one institution from 2012 to 2015. Patients who were at least 1 year out from surgery were included. Patient demographic characteristics, operative details, perioperative and postoperative complications, and recurrences were analyzed. Postoperative imaging was reviewed for evidence of morbidity or recurrence.

RESULTS

Thirty-seven patients met inclusion criteria; 23 (62.2%) of these patients were female, with a mean age of 57.5 ± 11 years and median BMI of 32.1 kg/m(2) (range 23.6 to 44.0 kg/m(2)). All patients underwent repair with mesh (81.1% polypropylene, 5.4% porcine dermal matrix, and 13.5% biologic/permanent synthetic hybrid). Median defect size was 392 cm(2) (range 250 to 2,700 cm(2)) and median mesh area was 930 cm(2) (range 600 to 3,600 cm(2)). Approximately 24% (9 of 37) of patients experienced a postoperative complication; ileus was the most common (4 patients). Surgical site events requiring intervention (ie drainage and antibiotics) developed in 2 patients. Median follow-up period was 21 months (range 12 to 42 months), during which one recurrence was identified (2.7%).

CONCLUSIONS

Posterior component separation via transversus abdominis release is a safe and effective method of ventral herniorrhaphy with favorable rates of wound morbidity and recurrence.

[Hernia recurrence long term follow-up after open procedures of abdominal wall plasty-prospective study including 142 patients]

BACKGROUND

The incisional hernia continues to be a frequent complication of laparotomies. The purpose of study is the analysis of hernia disease relapse after one year after different open plasties methods of the abdominal wall.

MATERIAL AND METHODS

A prospective longitudinal study was performed that included 142 patients. An analysis was performed on the individual data, the level of obesity, intra-surgical variations in intra-abdominal pressure, the intensity of post-surgical pain, the post-surgical complications, and the types of plasties of abdominal wall, simple and with polypropylene mesh.

RESULTS

The analysis of studied group showed a general rate of relapse of 16.9%, and within the 4 procedures, 40.74% in the case of simple plasties, of 16.07% after the only plasties, 6.97% after the retro-muscular plasties, and 6.25% after the full substitution of parietal defect. On analysing the collected, hernia relapse was statistically significantly related to the level of obesity, variations in intra-abdominal pressure, post-surgical pain, and the type of procedure performed.

CONCLUSIONS

Hernia is a frequent complication of laparotomies. Hernia relapse was more frequent in the case of simple plasties. Among the mesh procedures, the onlay plasty showed a higher rate of relapse and post-surgical complications. Hernia relapse was more frequent in the case of variations of intra-abdominal pressure, and with increased post-surgical pain. The use of an echography examination may increase the accuracy of the presence of hernia disease.

Patient awareness and symptoms from an incisional hernia

Incisional hernia is a common postoperative complication following open abdominal surgery with incidence varying between 3% and 20%.¹ Approximately half of all incisional hernias are diagnosed within 1 year following surgery. In the United Kingdom alone, about 10,000 incisional hernia repairs are performed annually. Incisional hernia repairs are generally elective with emergency repair due to incarceration or strangulation constituting about 15% of repairs.¹ Incisional hernia repair is not a low-risk operation and generally has relatively poor results due to chronic postoperative pain and high recurrence rates.²⁻³ Little has been published on patients' awareness of incisional hernia following open abdominal surgery. Moreover, there are very few publications on indications for incisional hernia repair and on the natural course of such hernias. The literature suggests that symptoms and complaints usually presented by patients include pain, discomfort, cosmetic complaints, skin problems, incarceration, strangulation, functional disability, and pulmonary dysfunction.⁴⁻⁶ The aim of this study was to investigate whether patients were aware that they had a hernia. In addition, we sought to determine symptoms for those who knew that they had an incisional hernia.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]

BACKGROUND

The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues.

METHODS

The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group.

RESULTS AND CONCLUSIONS

The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.

Intracorporeal ileocolic anastomosis in patients with laparoscopic right hemicolectomy

BACKGROUND

Since the introduction of laparoscopic colorectal surgery, there has been a controversy between creating an intracorporeal or extracorporeal ileocolic anastomosis in right hemicolectomy. The purpose is to report our experience in intracorporeal anastomosis following right hemicolectomy in both malignant and benign pathologies.

STUDY DESIGN

A retrospective review of a prospectively collected database was conducted at Virgen de la Arrixaca Clinical University Hospital (Murcia) between January 2000 and April 2014. The study includes all surgery patients who received a laparoscopic right hemicolectomy with an intracorporeal ileocolic anastomosis. The criteria for exclusion were conversion to open surgery during the procedure due to technical difficulties during dissect. Tumours considered T4 were not excluded, nor were stage IV patients or those with a history of previous abdominal surgery.

RESULTS

There were 173 patients (63 females) aged 67 (range 14-91) years, with body mass index of 27 (17-52) kg/m(2) and ASA 1:2:3:4 of 12:78:68:15; 41% had previous abdominal surgery and 70% had a pre-existing comorbidity. Operating time was 142 (60-270) min. Specimen extraction site incision length was 8.1 (6-11.1) cm. Conversion rate was 9.2%, and there were 39 complications (22.54%) and 9 reoperations (5.2%). Readmission rate was 5.2%. Length of stay was 5.7 (1-35) days.

CONCLUSION

The intracorporeal procedure is a safe and feasible alternative for creating an ileocolic anastomosis. It involves a similar rate of complications and may prevent some of the drawbacks presented by extracorporeal anastomosis.

Physiology in Medicine: physiological basis of diaphragmatic dysfunction with abdominal hernias-implications for therapy

An incisional hernia is a common complication after abdominal surgery. Complaints of dyspnea in this population may be attributed to cardiopulmonary dysfunction or deconditioning. Large abdominal incisional hernias, however, may cause diaphragm dysfunction and result in dyspnea, which is more pronounced when standing (platypnea). The use of an abdominal binder may alleviate platypnea in this population. We discuss the link between diaphragm dysfunction and the lack of abdominal wall integrity and how abdominal wall support partially restores diaphragm function.

The influence of laparoscopy on incisional hernia rates: a retrospective analysis of 1057 colorectal cancer resections

AIM

The aim of this study was to evaluate the incidence of incisional hernia formation after laparoscopic and open surgery for colorectal cancer.

METHOD

A retrospective analysis was conducted of 1057 colorectal cancer resection cases (289 laparoscopic, 768 open) performed in a single national laparoscopic training centre between January 2006 and December 2011. Clinical notes and serial computed tomography scans were reviewed, with any incisional hernia including those at a surgical incision, port site, stoma and stoma closure site identified and the size of the defect measured.

RESULTS

The overall incisional hernia rate was 14.8%. There was no significant difference between the open and laparoscopic groups (14.4% vs 15.9%, P = 0.566). Excluding stoma-related hernia, 10.7% of the open group developed a surgical wound hernia, and 11.1% of the laparoscopic group developed a hernia at a port site, extraction site or surgical midline incision. There was no statistical difference between the two groups (P = 0.853). The defects were smaller in the laparoscopic group (P < 0.005). There were significantly more parastomal hernias in the laparoscopic group (40%) than in the open group (12.7%, P < 0.001).

CONCLUSION

The incidence of incisional hernia formation was similar after laparoscopic or open surgery for colorectal cancer. Parastomal hernia was more frequent after laparoscopic surgery.

Retracted: Impact on quality of life of using an onlay mesh to prevent incisional hernia in midline laparotomy: a randomized clinical trial

BACKGROUND

Recent studies have demonstrated the effectiveness of using prophylactic meshes to achieve abdominal wall closure, decreasing the risk of incisional hernia. However, the effect of prophylactic mesh placement on a patient's quality of life has not yet been evaluated.

STUDY DESIGN

A controlled, prospective, randomized, and blind study was carried out. The patients in group A (mesh) were fitted with a polypropylene mesh to reinforce the standard abdominal wall closure. The patients in group B (nonmesh) were given a standard abdominal wall closure and were not fitted with the mesh. All patients were administered the 36-Item Short-Form generic health questionnaire during their preoperation visit and during their 1-month, 6-month, and 1-year follow-up appointments. The scores of the questionnaires have been compared with those recorded when the questionnaire was administered before surgery.

RESULTS

The Kaplan-Meier survival curves show that the likelihood of incisional hernia at 12 months is 1.5% in mesh group compared with 35.9% in nonmesh group (p > 0.0001), which means that the differences are statistically significant. Patients with mesh placement had greater improvement in general health and bodily pain than patients in nonmesh group at 1-month and 6-month post operation. One year after operation, patients in the mesh group had statistically significant better quality of life than patients in the nonmesh group in the physical functioning, general health perceptions, vitality, social role functioning, mental health, physical component summary and mental component summary dimensions.

CONCLUSIONS

Fitting a prophylactic supra-aponeurotic mesh prevents incisional hernia.

Pain and its effects on physical activity and quality of life before operation in patients undergoing elective inguinal and ventral hernia repair. Am J Surg. 2014;208:406-411. [PMID: 24997490 DOI: 10.1016/j.amjsurg.2014.02.011]

BACKGROUND

Pain is the most common symptom associated with hernias. The aim was to assess the frequency of pain and its effects on physical activity and quality of life in patients with inguinal and ventral hernias.

METHODS

All patients undergoing elective inguinal or ventral hernia repair over a 16-month period were asked to complete a questionnaire including a 4-point Verbal Rating Scale, Visual Analog Scale, and Brief Pain Inventory (BPI) to assess pain severity and interference.

RESULTS

One hundred twenty-four patients (72 inguinal, 52 ventral) completed the questionnaire and 75% registered pain on the BPI. There was good correlation between scoring systems (correlation coefficient >.8). Ventral hernia patients had more pain (P = .037), interference with mood (P = .027), sleep (P = .004), relation with other people (P = .019), and enjoyment of life (P = .029) than their inguinal hernia counterparts.

CONCLUSIONS

The BPI is an easy and effective way of assessing pain and its impact on physical activity and quality of life in patients with an inguinal or ventral hernia with most experiencing mild to moderate chronic pain and disability.

Importance of recurrence rating, morphology, hernial gap size, and risk factors in ventral and incisional hernia classification

BACKGROUND

There is limited evidence on the natural course of ventral and incisional hernias and the results of hernia repair, what might partially be explained by the lack of an accepted classification system. The aim of the present study is to investigate the association of the criteria included in the Wuerzburg classification system of ventral and incisional hernias with postoperative complications and long-term recurrence.

METHODS

In a retrospective cohort study, the data on 330 consecutive patients who underwent surgery to repair ventral and incisional hernias were analyzed. The following four classification criteria were applied: (a) recurrence rating (ventral, incisional or incisional recurrent); (b) morphology (location); (c) size of the hernial gap; and (d) risk factors. The primary endpoint was the occurrence of a recurrence during follow-up. Secondary endpoints were incidence of postoperative complications. Independent association between classification criteria, type of surgical procedures and postoperative complications was calculated by multivariate logistic regression analysis and between classification criteria, type of surgical procedures and risk of long-term recurrence by Cox regression analysis.

RESULTS

Follow-up lasted a mean 47.7 ± 23.53 months (median 45 months) or 3.9 ± 1.96 years. The criterion "recurrence rating" was found as predictive factor for postoperative complications in the multivariate analysis (OR 2.04; 95 % CI 1.09-3.84; incisional vs. ventral hernia). The criterion "morphology" had influence neither on the incidence of the critical event "recurrence during follow-up" nor on the incidence of postoperative complications. Hernial gap "width" predicted postoperative complications in the multivariate analysis (OR 1.98; 95 % CI 1.19-3.29; ≤5 vs. >5 cm). Length of the hernial gap was found to be an independent prognostic factor for the critical event "recurrence during follow-up" (HR 2.05; 95 % CI 1.25-3.37; ≤5 vs. >5 cm). The presence of 3 or more risk factors was a consistent predictor for "recurrence during follow-up" (HR 2.25; 95 % CI 1.28-9.92). Mesh repair was an independent protective factor for "recurrence during follow-up" compared to suture (HR 0.53; 95 % CI 0.32-0.86).

CONCLUSIONS

The ventral and incisional hernia classification of Dietz et al. employs a clinically proven terminology and has an open classification structure. Hernial gap size and the number of risk factors are independent predictors for "recurrence during follow-up", whereas recurrence rating and hernial gap size correlated significantly with the incidence of postoperative complications. We propose the application of these criteria for future clinical research, as larger patient numbers will be needed to refine the results.

Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. Am J Surg. 2012;204:144-150. [PMID: 22579232 DOI: 10.1016/j.amjsurg.2012.01.012]

BACKGROUND

We investigated the impact of incisional hernia (IH) on quality of life and body image.

METHODS

Open abdominal surgery patients were included in a prospective cohort study performed between 2007 and 2009 in an academic hospital. Main outcomes were incidence of IH after approximately 12 months and Short-Form 36 and body image questionnaire results.

RESULTS

There were 374 patients who were examined after a median follow-up period of 16 months (range, 10-24 mo). Seventy-five patients had developed IH (20%); 63 (84%) were symptomatic. Adjusted for age, sex, and Charlson Comorbidity Index score, patients with IH reported significantly lower mean scores for components physical functioning (P = .033), role physical (P = .002), and physical component summary (P = .010). A trend toward significance was found for general health (P = .061). Patients with IH reported significantly lower mean cosmetic scores (P = .002), and body image and total body image scores (both P < .001).

CONCLUSIONS

Patients with IH reported lower mean scores on physical components of health-related quality of life and body image.

Case report: incisional hernia as a complication of extreme lateral interbody fusion

BACKGROUND CONTEXT

Minimal access surgery is becoming more popular for spinal fusion because of a lower theoretical risk of complications and shorter postoperative recovery period, compared with the traditional open approach. The lateral approach uses retroperitoneal transpsoas access to the vertebra, obviating the need for an approach surgeon and minimizing muscular disruption, thus allowing a quicker recovery. Initial reports of the lateral transpsoas procedure described few complications. However, a number of complications have subsequently been documented. To our knowledge, there has not been a description of an incisional hernia after this approach.

PURPOSE

To report the rare complication of an incisional hernia after a minimal access lateral transpsoas approach for lumbar interbody fusion.

STUDY DESIGN

Case report.

METHODS

We reviewed the hospital charts, radiographs, and intraoperative photographs of a patient who underwent a minimally invasive lateral approach lumbar spine fusion with a subsequent incisional hernia that necessitated laparoscopic repair.

RESULTS

A 75-year-old woman with a history of low back and left lower extremity pain with radiographic evidence of foraminal stenosis and degenerative spondylolisthesis underwent a successful L4-L5 discectomy with an extreme lateral interbody fusion via a retroperitoneal transpsoas approach. This was supplemented with a posterior minimally invasive surgery instrumented fusion from L4 to L5. The patient reported significant improvement in symptoms on initial follow-up, however, complained of a prominence over her incision 4 weeks later. An incisional hernia was diagnosed and subsequently repaired laparoscopically, from which the patient recovered uneventfully.

CONCLUSIONS

Postoperative incisional hernia after extreme lateral interbody fusion is a complication that has not been previously described in the literature but is one that spine surgeons must recognize. This case may prompt surgeons to use a more posterior approach to avoid this complication. Additionally, direct repair of the transversalis fascia is critical to avoiding this complication.

Development of a clinical trial to determine whether watchful waiting is an acceptable alternative to surgical repair for patients with oligosymptomatic incisional hernia: study protocol for a randomized controlled trial

BACKGROUND

Incisional hernia is a frequent complication in abdominal surgery. This article describes the development of a prospective randomized clinical trial designed to determine whether watchful waiting is an acceptable alternative to surgical repair for patients with oligosymptomatic incisional hernia.

METHODS/DESIGN

This clinical multicenter trial has been designed to compare watchful waiting and surgical repair for patients with oligosymptomatic incisional hernia. Participants are randomized to watchful waiting or surgery and followed up for two years. The primary efficacy endpoint is pain/discomfort during normal activities as a result of the hernia or hernia repair two years after enrolment, as measured by the hernia-specific Surgical Pain Scales (SPS). The target sample size of six hundred thirty-six patients was calculated to detect non-inferiority of the experimental intervention (watchful waiting) in the primary endpoint. Sixteen surgical centers will take part in the study and have submitted their declaration of commitment giving the estimated number of participating patients per year. A three-person data safety monitoring board will meet annually to monitor and supervise the trial.

DISCUSSION

To date, we could find no published data on the natural course of incisional hernias. To our knowledge, watchful waiting has never been compared to standard surgical repair as a treatment option for incisional hernias. A trial to compare the outcome of the two approaches in patients with oligosymptomatic incisional hernias is urgently needed to provide data that can facilitate the choice between treatment options. If watchful waiting was equal to surgical repair, the high costs of surgical repair could be saved. The design for such a trial is described here. This multicenter trial will be funded by the German Research Foundation (DFG). The ethics committee of the Charité has approved the study protocol. Approval has been obtained from ten study sites at time of this submission. The electronic Case Report Forms have been created. The first patient was to be randomized November 14th, 2011. An initiation meeting took place in Berlin January 9th, 2012.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01349400.

A hybrid technique for recurrent incisional hernia repair

PURPOSE

The aim of this technical report is to investigate the safety and effectiveness of a hybrid technique for recurrent incisional hernia repair, which combines the conventional and laparoscopic approaches.

METHODS

Six patients suffering from recurrent and complicated incisional hernias underwent a hybrid technique for their repair. The open part of the operation ensured extensive and safe adhesiolysis, reduction of the hernia content into the peritoneal cavity, and proper placement of the bowel loops into the peritoneal cavity, minimizing the risk of bowel perforation. For the laparoscopic part of the procedure, intraperitoneal (underlay) e-PTFE mesh placement, of the appropriate size covering the actual hernia size and the scar edges for at least 3 cm, was laparoscopically fixated by transfascial stay stitches, allowing stretch of the mesh on the anterior abdominal wall, probably avoiding the mesh deformation in the future.

RESULTS

The overall size of the fascial defect was calculated between 116 and 187 cm, the size of the mesh used ranged from 308 to 468 cm, the total operative time ranged from 128 to 207 minutes and within a maximum follow-up period of 12 months, all patients are asymptomatic without any evidence of hernia recurrence.

CONCLUSIONS

The hybrid technique is safe in cases of recurrent or complicated or difficult incisional hernias. A longer follow-up period is required to estimating the effectiveness and the cost-effectiveness of the method.

Isokinetic strength of the trunk flexor muscles after surgical repair for incisional hernia

Purpose

The repair of incisional hernias can be accomplished by open or laparoscopic techniques. The Biodex^® dynamometer measures muscle strength during isokinetic movement. The objectives of this study are to compare the strength of the trunk flexors between patients who underwent repair for incisional hernia and a control group, and to compare trunk flexion after two kinds of operative techniques for incisional hernias with and without approximation of the rectus abdominis muscles.

Methods

The trunk flexion of 30 patients after different operative techniques for midline incisional hernias and of 12 healthy subjects was studied with the Biodex^® isokinetic dynamometer.

Results

The mean torque/weight (N m/kg) for trunk flexion was significantly higher in the control group compared to the patient group after incisional hernia repair. A significantly higher peak torque/weight [coefficient 24.45, 95% confidence interval (CI) −0.05; 48.94, P = 0.05] was found in the two-layered suture technique without mesh compared to the laparoscopic technique after adjusting for gender.

Conclusions

The isokinetic strength of the trunk flexor muscles is reduced after an operation for incisional hernia. There is some evidence that a two-layered suture repair with approximation of the rectus abdominis muscles results in higher isokinetic strength of the trunk flexor muscles compared to the laparoscopic technique.

Pre-, intra-, and postoperative sonography of the abdominal wall in patients with incisional hernias repaired via a three-layered operative suture method

We illustrate the various sonographic (US) appearances of the abdominal wall following this type of repair, including partial and complete recurrences. Correlation is made with CT imaging. The three-layered anatomical reconstruction of an incisional hernia is described.