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DeAngelo N, Perez AJ. Hernia Prevention: The Role of Technique and Prophylactic Mesh to Prevent Incisional Hernias. Surg Clin North Am 2023; 103:847-857. [PMID: 37709391 DOI: 10.1016/j.suc.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Millions of laparotomies are performed annually, carrying up to a 41% risk of developing into a hernia. Incisional hernias are associated with morbidity, mortality, and costs; an estimated $9.6 billion is spent annually on repair of ventral hernias. Although repair is possible, surgeons must prevent incisional hernias from occurring. There is substantial evidence on surgical technique to reduce the risk of incisional hernia formation. This article aims to critically summarize the use of surgical technique and prophylactic mesh augmentation during fascial closure to inform decision-making and reduce incisional hernia formation.
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Affiliation(s)
- Noah DeAngelo
- Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Arielle J Perez
- The University of North Carolina at Chapel Hill, Department of Surgery, 160 Dental Circle, Burnett-Womack, CB #7228, Chapel Hill, NC 27599-7228, USA.
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Abstract
A hiatus hernia is defined as a transdiaphragmatic protrusion/migration of the intrabdominal contents through the esophageal hiatus of the diaphragm. The classification of hiatus hernias is based on anatomical morphological differentiation (types I-IV). The leading symptoms and psychological stress vary with respect to the symptoms, e. g. reflux and compression symptoms. Gastroscopy and multichannel intraluminal impedance pH measurement are obligatory preoperative functional diagnostics. A distinction is made between frequent type I hernia (antireflux surgery), symptomatic paraesophageal, thoracic and mixed hernia types (II-IV). Surgical indications exist in symptomatic type II-IV hernias. Hiatal mesh augmentation reduces recurrences. The complication potential of synthetic meshes must be taken into account. Biological implants show no advantages.
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Jakob MO, Schwarz C, Haltmeier T, Zindel J, Pinworasarn T, Candinas D, Starlinger P, Beldi G. Mesh-augmented versus direct abdominal closure in patients undergoing open abdomen treatment. Hernia 2018; 22:785-792. [PMID: 30027445 PMCID: PMC6153946 DOI: 10.1007/s10029-018-1798-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/13/2018] [Indexed: 01/29/2023]
Abstract
Background Open abdomen (OA) may be required in patients with abdominal trauma, sepsis or compartment syndrome. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a widely used approach for temporary abdominal closure to close the abdominal wall. However, this method is associated with a high incidence of re-operations in short term and late sequelae such as incisional hernia. The current study aims to compare the results of surgical strategies of OA with versus without permanent mesh augmentation. Methods Patients with OA treatment undergoing vacuum-assisted wound closure and an intraperitoneal onlay mesh (VAC-IPOM) implantation were compared to VAWCM with direct fascial closure which represents the current standard of care. Outcomes of patients from two tertiary referral centers that performed the different strategies for abdominal closure after OA treatment were compared in univariate and multivariate regression analysis. Results A total of 139 patients were included in the study. Of these, 50 (36.0%) patients underwent VAC-IPOM and 89 (64.0%) patients VAWCM. VAC-IPOM was associated with reduced re-operations (adjusted incidence risk ratio 0.48 per 10-person days; CI 95% = 0.39–0.58, p < 0.001), reduced duration of stay on intensive care unit (ICU) [adjusted hazard ratio (aHR) 0.53; CI 95% = 0.36–0.79, p = 0.002] and reduced hospital stay (aHR 0.61; CI 95% = 0.040–0.94; p = 0.024). In-hospital mortality [22.5 vs 18.0%, risk difference − 4.5; confidence interval (CI) 95% = − 18.2 to 9.3; p = 0.665] and the incidence of intestinal fistula (18.0 vs 22.0%, risk difference 4.0; CI 95% = −10.0 to 18.0; p = 0.656) did not differ between the two groups. In Kaplan–Meier analysis, hernia-free survival was significantly increased after VAC-IPOM (p = 0.041). Conclusions In patients undergoing OA treatment, intraperitoneal mesh augmentation is associated with a significantly decreased number of re-operations, duration of hospital and ICU stay and incidence of incisional hernias when compared to VAWCM. Electronic supplementary material The online version of this article (10.1007/s10029-018-1798-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M O Jakob
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - C Schwarz
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - T Haltmeier
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - J Zindel
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - T Pinworasarn
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - D Candinas
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - P Starlinger
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - G Beldi
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland.
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Köckerling F, Botsinis MD, Rohde C, Reinpold W, Schug-Pass C. Endoscopic-assisted linea alba reconstruction: New technique for treatment of symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis. Eur Surg 2017; 49:71-75. [PMID: 28408920 PMCID: PMC5368206 DOI: 10.1007/s10353-017-0473-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 02/24/2017] [Indexed: 12/05/2022]
Abstract
Background Patients with symptomatic umbilical, trocar, and/or epigastric hernias and concomitant rectus abdominis diastasis represent a growing clinical problem. The optimal management of this complex hernia situation is the subject of debate in the literature. This paper reports the early results of an innovative surgical technique aimed at managing this hernia situation. Methods Endoscopic-assisted linea alba reconstruction (ELAR) with mesh augmentation is a surgical technique long known in the literature for its good outcome for incisional hernia repair (myofascial release, overlapping herniorrhaphy, Gibson’s operation, shoelace repair, anterior rectus sheath repair, dynamic patch plasty) via a small access route. The early results for 140 patients are presented here. Results Two patients (1.4%) developed postoperative complications requiring redo surgery. These were two cases of diffuse secondary bleeding without an identifiable bleeding source, in one patient with liver cirrhosis and portal hypertension and in another patient receiving treatment with platelet aggregation inhibitors. All other complications were successively managed with conservative treatment. After 1 year, two of 30 patients reported occasional pain, including pain at rest in one patient. Conclusion The ELAR technique with mesh augmentation is an innovative, minimally invasive surgical procedure for treatment of patients with a complex abdominal wall hernia comprising symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis.
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Affiliation(s)
- Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585 Berlin, Germany
| | - Marinos Damianos Botsinis
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585 Berlin, Germany
| | - Christine Rohde
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585 Berlin, Germany
| | - Wolfgang Reinpold
- Department of Surgery and Hernia Center, Wilhelmsburg Hospital Gross-Sand, Gross-Sand 3, 21107 Hamburg, Germany
| | - Christine Schug-Pass
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585 Berlin, Germany
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Weintraub AY, Friedman T, Baumfeld Y, Neymeyer J, Neuman M, Krissi H. Long-term functional outcomes following mesh-augmented posterior vaginal prolapse repair. Int J Gynaecol Obstet 2016; 135:107-11. [PMID: 27484924 DOI: 10.1016/j.ijgo.2016.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 03/29/2016] [Accepted: 06/06/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess long-term patient-centered functional outcomes following posterior vaginal wall repair using mesh implants. METHOD The present prospective telephone interview study enrolled a cohort of women who had undergone posterior vaginal wall repair with mesh between January 1, 2006 and February 28, 2009, at a single center in Israel. Patients were asked to report long-term outcomes, and demographic, clinical, intraoperative, and postoperative follow-up data were retrieved from patients' medical files. Multivariable logistic regression models were used to asses associations between baseline characteristics and long-term outcomes. RESULTS In total, 102 patients were contacted, with 80 (78.4%) at 61-83months after surgery agreeing to participate. A recurrence of prolapse symptoms was reported by 14 patients (18%) (12 required a corrective procedure), mesh had been removed from two patients owing to erosion/extrusion, and two others had undergone removal of granulation tissue. Long-term, bothersome symptoms were reported by 13 (16%) patients. Parity and previous hysterectomy were associated with lower odds of long-term adverse outcomes, and the location of the apical (C/D) pelvic organ prolapse quantification point and a change in its position following surgery were associated with increased odds of adverse outcomes. CONCLUSION The long-term adverse-outcome rate was low for patients who underwent posterior vaginal mesh augmentation. These results highlight the importance of apical support for good long-term functional outcomes.
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Gillion JF, Sanders D, Miserez M, Muysoms F. The economic burden of incisional ventral hernia repair: a multicentric cost analysis. Hernia 2016; 20:819-830. [PMID: 26932743 DOI: 10.1007/s10029-016-1480-z] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 02/17/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE A systematic review of literature led us to take note that little was known about the costs of incisional ventral hernia repair (IVHR). METHODS Therefore we wanted to assess the actual costs of IVHR. The total costs are the sum of direct (hospital costs) and indirect (sick leave) costs. The direct costs were retrieved from a multi-centric cost analysis done among a large panel of 51 French public hospitals, involving 3239 IVHR. One hundred and thirty-two unitary expenditure items were thoroughly evaluated by the accountants of a specialized public agency (ATIH) dedicated to investigate the costs of the French Health Care system. The indirect costs (costs of the post-operative inability to work and loss of profit due to the disruption in the ongoing work) were estimated from the data the Hernia Club registry, involving 790 patients, and over a large panel of different Collective Agreements. RESULTS The mean total cost for an IVHR in France in 2011 was estimated to be 6451€, ranging from 4731€ for unemployed patients to 10,107€ for employed patients whose indirect costs (5376€) were slightly higher than the direct costs. CONCLUSION Reducing the incidence of incisional hernia after abdominal surgery with 5 % for instance by implementation of the European Hernia Society Guidelines on closure of abdominal wall incisions, or maybe even by use of prophylactic mesh augmentation in high risk patients could result in a national cost savings of 4 million Euros.
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Affiliation(s)
- J-F Gillion
- Unité de Chirurgie Viscérale et Digestive, Hôpital Privé d'Antony, Antony, France.
| | - D Sanders
- Department of Surgery, Derriford Hospital, Plymouth, UK
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals, KU Leuven, Leuven, Belgium
| | - F Muysoms
- Department of Abdominal Surgery, AZ Maria Middelares, Ghent, Belgium
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Weintraub AY, Friedman T, Baumfeld Y, Neuman M, Krissi H. Long term subjective cure rate, urinary tract symptoms and dyspareunia following mesh augmented anterior vaginal wall prolapse repair. Int J Surg 2015; 24:33-8. [PMID: 26525268 DOI: 10.1016/j.ijsu.2015.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/03/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The aim of this study was to assess patient-centered long term outcomes following anterior vaginal repair with mesh. METHODS In January 2015, we identified 124 women who underwent anterior pelvic floor repair with mesh between January 2006 and February 2009. Patient records were reviewed and demographic, clinical, intra-operative and post-operative follow-up data retrieved. Telephone interviews were conducted to access information on clinical outcomes. Associations between baseline characteristics and long term symptoms were assessed by multivariable logistic regression models. RESULTS Seventy-nine women were reached and consented to participate. Patients were interviewed 79-104 months after surgery. Their mean age at the time of surgery was 62.48 ± 9.53 years; all had stage III cystocele with a mean POP Q point Ba of 5.32 ± 1.47. Twenty-four (30%) had a previous hysterectomy and 26 (33%) had a previous pelvic organ prolapse or stress urinary incontinence operation. At telephone interviews, recurrence of prolapse symptoms was reported by 11 (13.9%) patients, mostly in the posterior compartment. Only 6 needed a corrective procedure. One patient had her mesh removed due to dyspareunia. Eleven (13.9%) reported lower urinary tract symptoms other than prolapse, as follows: stress urinary incontinence (1), overactive bladder (8) and dyspareunia (2). CONCLUSION Long term rates of recurrent prolapse, dyspareunia and lower urinary tract symptoms were low for patients who underwent anterior vaginal wall mesh augmentation surgery for symptomatic cystoceles.
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Affiliation(s)
- A Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Beer Sheva 85025, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel.
| | - T Friedman
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
| | - Y Baumfeld
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Beer Sheva 85025, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel; Clinical Research Center, Soroka University Medical Center, Beer Sheva 85025, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel.
| | - M Neuman
- Urogynecology, Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, and the Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel; Assuta Medical Centers, Tel Aviv and Rishon LeZion, Israel.
| | - H Krissi
- Urogynecology Unit, Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Petach Tikva 49100, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel.
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