The causal association between body fat distribution and risk of abdominal wall hernia: a two-sample Mendelian randomization study

PURPOSE

Obesity and a high body mass index (BMI) are considered as risk factors for abdominal wall hernia (AWH). However, anthropometric measures of body fat distribution (BFD) seem to be better indicators in the hernia field. This Mendelian randomization analysis aimed to generate more robust evidence for the impact of waist circumstance (WC), body, trunk, arm, and leg fat percentages (BFP, TFP, AFP, LFP) on AWH.

METHODS

A univariable MR design was employed and the summary statistics allowing for assessment were obtained from the genome-wide association studies (GWASs). An inverse variance weighted (IVW) method was applied as the primary analysis, and the odds ratio value was used to evaluate the causal relationship between BFD and AWH.

RESULTS

None of the MR-Egger regression intercepts deviated from null, indicating no evidence of horizontal pleiotropy (p > 0.05). The Cochran Q test showed heterogeneity between the genetic IVs for WC (p = 0.005; p = 0.005), TFP (p < 0.001; p < 0.001), AFP-L (p = 0.016; p = 0.015), LFP-R (p = 0.012; p = 0.009), and LFP-L (p < 0.001; p < 0.001). Taking the IVW random-effects model as gold standard, each standard deviation increment in genetically determined WC, BFP, TFP, AFP-R, AFP-L, LFP-R, and LFP-L raised the risk of AWH by 70.9%, 70.7%, 56.5%, 69.7%, 78.3%, 87.7%, and 72.5%, respectively.

CONCLUSIONS

This study proves the causal relationship between AWH and BFD, attracting more attention from BMI to BFD. It provides evidence-based medical evidence that healthy figure management can prevent AWH.

Health Insurance Status and Unplanned Surgery for Access-Sensitive Surgical Conditions

Importance

Access-sensitive surgical conditions, such as abdominal aortic aneurysm, ventral hernia, and colon cancer, are ideally treated with elective surgery, but when left untreated have a natural history requiring an unplanned operation. Patients' health insurance status may be a barrier to receiving timely elective care, which may be associated with higher rates of unplanned surgery and worse outcomes.

Objective

To evaluate the association between patients' insurance status and rates of unplanned surgery for these 3 access-sensitive surgical conditions and postoperative outcomes.

Design, Setting, and Participants

This cross-sectional cohort study examined a geographically broad patient sample from the Healthcare Cost and Utilization Project State Inpatient Databases, including data from 8 states (Arizona, Colorado, Florida, Kentucky, Maryland, North Carolina, Washington, and Wisconsin). Participants were younger than 65 years who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2016 and 2020. Patients were stratified into groups by insurance status. Data were analyzed from June 1 to July 1, 2023.

Exposure

Health insurance status (private insurance, Medicaid, or no insurance).

Main Outcomes and Measures

The primary outcome was the rate of unplanned surgery for these 3 access-sensitive conditions. Secondary outcomes were rates of postoperative outcomes including inpatient mortality, any hospital complications, serious complications (a complication with a hospital length of stay longer than the 75th percentile for that procedure), and hospital length of stay.

Results

The study included 146 609 patients (mean [SD] age, 50.9 [10.3] years; 73 871 females [50.4%]). A total of 89 018 patients (60.7%) underwent elective surgery while 57 591 (39.3%) underwent unplanned surgery. Unplanned surgery rates varied significantly across insurance types (33.14% for patients with private insurance, 51.46% for those with Medicaid, and 72.60% for those without insurance; P < .001). Compared with patients with private insurance, patients without insurance had higher rates of inpatient mortality (1.29% [95% CI, 1.04%-1.54%] vs 0.61% [0.57%-0.66%]; P < .001), higher rates of any complications (19.19% [95% CI, 18.33%-20.05%] vs 12.27% [95% CI, 12.07%-12.47%]; P < .001), and longer hospital stays (7.27 [95% CI, 7.09-7.44] days vs 5.56 [95% CI, 5.53-5.60] days, P < .001).

Conclusions and Relevance

Findings of this cohort study suggest that uninsured patients more often undergo unplanned surgery for conditions that can be treated electively, with worse outcomes and longer hospital stays compared with their counterparts with private health insurance. As efforts are made to improve insurance coverage, tracking elective vs unplanned surgery rates for access-sensitive surgical conditions may be a useful measure to assess progress.

Operative efficiency: a comparative analysis of Versius and da Vinci robotic systems in abdominal surgery

Robotic-assisted surgery has gained momentum in the pursuit of improved minimally invasive procedures. The adoption of new robotic platforms, such as the Versius, raises concerns about safety, efficacy, and learning curves. This study compares the Versius to the well-established da Vinci in terms of operative time and patient population. Retrospective data collection was conducted on patient data from inguinal hernia surgery, ventral hernia surgery, and cholecystectomies performed between February 2022 and March 2023 at the American Hospital of Dubai. Only experienced cases were included, ensuring proficiency with robotic technology. Versius had longer procedure times in inguinal and ventral hernia surgeries but not in cholecystectomy. No intraoperative complications were observed in either system. This study demonstrates that Versius can provide comparable outcomes to the da Vinci in abdominal surgery, with no observed intraoperative complications.

Numerical investigation of a finite element abdominal wall model during breathing and muscular contraction

BACKGROUND AND OBJECTIVE

Ventral hernia repair is faced with high recurrence rates. The personalization of the diagnosis, the surgical approach and the choice of the prosthetic implant seem relevant axes to improve the current results. Numerical models have the potential to allow this patient-specific approach, yet currently existing models lack validation. This work extensively investigated a realistic finite element abdominal wall model including the implementation of muscle activation.

METHODS

A parametric 3D finite element model composed of bone, muscle and aponeurotic structures was introduced. Hyperelastic anisotropic materials were implemented. Two loading scenarios were simulated: passive inflation of the abdominal cavity to represent, e.g., breathing, and passive inflation followed by muscular activation to simulate other daily activities such as cough. The impact of the inter-individual variability (e.g., BMI, tissue thickness, material properties, intra-abdominal pressure (IAP) and muscle contractility) on the model outputs was studied through a sensitivity analysis.

RESULTS

The overall model predictions were in good agreement with the experimental data in terms of shape variation, muscles displacements, strains and midline forces. A total of 34 and 41 runs were computed for the passive and active sensitivity analysis respectively. The regression model fits rendered high R-squared in both passive (84.0 ± 6.7 %) and active conditions (82.0 ± 8.3 %). IAP and muscle thickness were the most influential factors for the selected outputs during passive (breathing) activities. Maximum isometric stress, muscle thickness and pre-activation IAP were found to drive the response of the simulations involving muscular contraction. The material properties of the connective tissue were essential contributors to the behaviour of the medial part of the abdominal wall.

CONCLUSIONS

This work extensively investigated a realistic abdominal wall model and evaluated its robustness using experimental data from literature. Such a model could improve patient-specific simulation for ventral hernia surgical planning, prevention, and repair or implant evaluation. Further investigations will be conducted to evaluate the impact of the surgical technique and the mechanical characteristic of prosthetic meshes on the model outputs.

Patient outcomes and cost in robotic emergency general surgery

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

Vasovagal Pre-Syncope Induced by Epidural Electrical Stimulation Test: A Rare Case Report in a 61-Year-Old Woman Undergoing Ventral Hernia Repair

BACKGROUND Thoracic epidural analgesia is a commonly applied technique for perioperative pain management in major thoraco-abdominal surgery, but is complicated by high failure rates. The epidural electrical stimulation test (EEST) or "Tsui test" is a safe and effective method whereby low electrical current is used to confirm correct epidural catheter position and decrease the variability in analgesic effectiveness of the neuraxial technique. CASE REPORT We present the case of a 61-year-old woman with no prior cardiac or pulmonary comorbidities who was scheduled to undergo a ventral and parastomal hernia repair with component separation. The patient was offered a low thoracic epidural for perioperative analgesia. Technical aspects of the siting of the epidural catheter were uneventful and a confirmatory Tsui test was planned. At the initiation of electrical stimulation via the epidural catheter to confirm optimal catheter positioning, the patient experienced symptomatic bradycardia and hemodynamic instability that persisted despite terminating the electrical stimulation, and required pharmacologic intervention. CONCLUSIONS This report describes a rare case of vasovagal pre-syncope associated with the EEST or Tsui test. Although vasovagal reactions can be commonly associated with neuraxial procedures due to augmented venous return or severe emotional stress, we raise the possibility that through direct electrical stimulation in the epidural space, the EEST may have the potential to trigger such a physiologic response.

Health-related quality of life in abdominal wall hernia: let's ask patients what matters to them?

INTRODUCTION

Quality of Life (QoL) is an important consideration in patients with abdominal wall hernia (AWH). What matters to patients and their everyday experience living with AWH may depend on a variety of personal, psychological, social and environmental factors. At present, no study has addressed what is important to this particular group of patients by asking the patients themselves. This study aims to determine QoL from the patient's perspective by examining the lived experience in this patient population.

METHODS

We interviewed 15 patients with AWH until thematic saturation. The patients were purposively sampled from AWH clinic between February 2020 and June 2020 using topic guides and interview schedules. Verbatim interview transcripts were coded and analysed using NVivo12 software and Interpretative Phenomenological Analysis (IPA). We adhered to consolidated criteria for reporting qualitative research (COREQ).

RESULTS

Fifteen participants (8 men and 7 women) of age range 36-85 years, median 65 years, covering all Ventral Hernia Working Group (VHWG) grades. Five superordinate themes were identified each with several subordinate themes, as follows: (1) body image (subthemes-'changes to perceptions of self' and 'fears concerning perceptions of others'). (2) Mental health (subthemes-'emotional responses', 'disruptions to previously solid aspects of identity', 'developing coping strategies'). (3) Symptoms (subthemes-'managing pain', 'freedom of movement', 'restriction and adaptation of function'). (4) Interpersonal relationships (subthemes-'difficulties socially connecting' and 'changes in sexual relations'). (5) Employment (subthemes-'financial pressure', 'return to work issues' and 'costs to family').

CONCLUSION

This is the first phenomenological qualitative study in the field of AWH and presents a rich account of what is important to these patients in terms of QoL. Developed from the patients' own words, the themes are interrelated and should shape our understanding of patients with AWH. This study provides qualitative examples of each theme. This study has identified new themes (body image, interpersonal relationships and employment) that are not incorporated in existing AWH-specific QoL instruments. This is important for surgeons because the study suggests that we are currently not capturing all data relevant to QoL in this specific patient group with current tools. The wider impact of this would be to help counsel patients and support them more holistically through the disease process and it's management. Further research is needed to generate a standardised AWH QoL instrument which incorporates bio-psycho-emotional-social themes important to patients, as identified by patients.

Update on surgical management of enteroatmospheric fistulae in intestinal failure patients

PURPOSE OF REVIEW

The surgical management of enteroatmospheric fistula (EAF) in patients with intestinal failure represents a major challenge for a surgical team and requires proficiency in sepsis management, nutritional support and prehabilitation, beside expertise in visceral and abdominal wall surgery. This review provides an update on the current recommendations and evidence.

RECENT FINDINGS

Reconstructive surgery should be performed at a minimum of 6-12 months after last laparotomy. Isolation techniques and new occlusion devices may accelerate spontaneous EAF closure in selected cases. Chyme reinfusion supports enteral and parenteral nutrition. Stapler anastomosis and failure to close the fascia increase the risk of EAF recurrence. Posterior component separation, intraoperative fascial tension and biological meshes may be used to accommodate fascial closure.

SUMMARY

Timing of reconstructive surgery and previous optimal conservative treatment is vital for favorable outcomes. Wound conditions, nutritional support and general patient status should be optimal before attempting a definitive fistula takedown. Single stage procedures with autologous gut reconstruction and abdominal wall reconstruction can be complex but well tolerated.

Handlebar Hernia: An Uncommon Traumatic Abdominal Hernia

ABSTRACT

Handlebar hernia is a type of traumatic abdominal wall hernia caused by the impact of a bicycle handlebar against the abdominal wall. A good anamnesis and physical examination are important for the correct diagnosis, and ultrasonography is an accessible tool in the emergency department for imaging confirmation. We describe a case of an 11-year-old girl who presented to the emergency department after an abdominal trauma caused by a handlebar. Ultrasonography revealed an abdominal wall defect with herniation of omentum and bowel loops. Conservative management was initially established, followed by surgical treatment due to persistent symptoms.

RECONSTRUCTION OF THE ABDOMINAL WALL DEFECTS USING GELATIN-COATED DECELLULARIZED AND LYOPHILIZED HUMAN AMNIOTIC MEMBRANE

Ventral hernias, with the incidence of reherniation nearly as high as 50%, still remain to be a real challenge for surgeons worldwide. The use of mesh in the repair of abdominal wall defects reduces the incidence of reherniation; however, using a prosthetic mesh can lead to complications like wound infection, hematoma, seroma, enterocutaneous fistula, small bowel obstruction, recurrent herniation and erosion into adjacent structures including the intestine. The aim of the study was to develop a method for producing gelatin-coated decellularized and lyophilized human amniotic membrane graft and to determine its effectiveness for the reconstruction of the anterior abdominal wall defects. Experiments were conducted on 40 Lewis white laboratory rats. Animals were divided into four equivalent groups. Abdominal wall defects were created in all rats and repaired using the ULTRAPROTM mesh (group I), ULTRAPROTM mesh which was covered by decellularized and lyophilized human amniotic membrane from both sides (group II), mesh from gelatin-coated decellularized and lyophilized human amniotic membrane (group III) and biological surgical mesh XI-S+® (group IV). Three months after implantation, meshes from gelatin-coated decellularized and lyophilized human amniotic membrane were integrated with host tissues so that it was difficult to distinguish it from the surrounding tissues. However, in the second group, ULTRAPROTM mesh was still detectable through the decellularized amniotic membrane. Encouraging results were also observed when using a XI-S+® graft. Three months after implantation, XI-S+® graft was surrounded by a well-defined connective tissue capsule and was tightly fixed to the host tissues. While using gelatin-coated decellularized and lyophilized human amniotic membrane grafts and XI-S+® grafts, all the defects were repaired successfully and none of the rats in these groups showed any evidence of bulging or herniation, development of wound rupture, wound infection or fistula formation in postoperative period. Gelatin-coated Decellularized human amniotic membrane can be used as anti-adhesive barrier in abdominal and pelvic surgery, as well as for the repair of the abdominal wall hernia.

Large Abdominal Wall Defects: A Safe and Reliable Technique for Midline Reconstruction-The Bonheiden Experience

This retrospective study reveals the results of our approach to the treatment of complex ventral hernias. A single-center, single-surgeon retrospective chart review on 68 consecutive patients who underwent abdominal wall reconstruction for incisional herniation on the midline between January 2012 and December 2016 is presented. The Bonheiden technique is based on anterior component separation in combination with preperitoneal retromuscular mesh reinforcement of the midline. Data of 68 consecutive cases of incisional midline abdominal wall defects treated electively with the mesh reinforced anterior component separation technique were analyzed. Demographics, patient characteristics, and hernia properties were evaluated. Postoperative complications included 28% of wound infections/dehiscence, 25% seromas, and 7% hematomas. No recurrences have been seen. We conclude this technique to be safe and reliable for large midline defects in patients suffering with several comorbidities.

Robotic-Assisted Transabdominal Preperitoneal Ventral Hernia Repair

Ventral hernia repair is one of the most common operations performed by surgeons worldwide. The widespread adoption of laparoscopic surgery has significantly reduced complications related to traditional open approaches. The most common approach in laparoscopic ventral hernia repair is the intraperitoneal onlay mesh (IPOM) approach. This technique, though simple to perform, has limitations, including bridging mesh, intraperitoneal positioning of mesh, transfascial fixation, circumferential mesh fixation, and the use of more expensive composite mesh materials. These limitations are magnified when hernias occur in anatomically difficult sites such as the subxiphoid, suprapubic, and flank regions. Robotic-assisted hernia repair using a transabdominal preperitoneal (TAPP) approach has emerged as a viable alternative to traditional IPOM by potentially addressing these limitations. We review the operative considerations, intraoperative approach, and current body of literature related to robotic-assisted TAPP ventral hernia repair and conclude that it is feasible and may result in improved outcomes related to the restoration of abdominal wall anatomy and reduced operative costs. Further studies are needed to assess if robotic-assisted TAPP should become the standard approach for repair of ventral hernia defects.

[Safety and feasibility of radical surgery for giant desmoid in abdominal wall]

OBJECTIVE

To evaluate the safety and feasibility of radical surgery for giant desmoid in abdominal wall accompanied with the repair of giant myofascial defect using synthetic prosthesis.

METHODS

We analyzed the clinical and follow-up data of 31 patients with giant desmoid in abdominal wall undergoing radical resection and immediate abdominal wall reconstruction with synthetic prosthesis from January 2007 to January 2017 retrospectively. Patients were recruited at the Diagnostic and Therapeutic Center of Hernia and Abdominal Wall Diseases, the First Affiliated Hospital of Chinese PLA General Hospital and the Department of General Surgery, Chinese PLA General Hospital. Operative conditions, morbidity of complication, short- and long-term outcomes were summarized. All the patients underwent radical resection and infiltrated organs or tissues were simultaneously treated. Synthetic prosthesis was used to perform primary-intention reconstruction of giant myofascial defect in anterior or lateral abdominal wall. Bridging repair procedure for incisional hernia was used to perform double border fixation between prosthesis border and myofascial defect border. Placement and fixation of prosthesis followed the idea of "conformal repair", then prosthesis was finally repaired as arch in accordance with original abdominal wall.

RESULTS

Of 31 patients, 28 cases were female with mean age of 35.2 (16-58) years and 3 were male with mean age of 42.6 (20-79) years. Six initial cases (19.4%) were diagnosed by preoperative biopsy, and 25 recurrent cases (60.6%) were diagnosed by medical history. The mean minimal diameter of tumors was 18.2 (14-25) cm, and the mean maximal diameter was 45.3 (32-53) cm. All 31 patients underwent radical resection and immediate abdominal wall reconstruction using synthetic prosthesis in bridging fashion successfully, and rapid pathological examination showed that all resection margins were negative. The average operative time was 335 (245-610) min, and the average intra-operative blood loss was 1260 (500-3500) ml. The size of abdominal wall defect after removal of desmoid ranged from 21 cm × 23 cm to 35 cm × 60 cm. The defects in 29 patients were repaired with compound synthetic prosthesis and the defects in 2 patients were repaired with compound prosthesis and polypropylene mesh. Four patients(12.9%) developed postoperative infection, in whom 3 patients had prosthesis infection during 1 month postoperatively, then 1 case recovered with conservative therapy, the other 2 cases were healed after the removal of infected prosthesis at 2 weeks and 3 months postoperatively, respectively; 1 patient had infection of artificial vessel prosthesis and received a second operation to remove the infected artificial vessel. The other 27 patients recovered smoothly and got primary intention wound healing. These 31 patients were followed up for a median of 60.5 (10-121) months with complete data. No marginal recurrence, incisional hernia, and abdominal wall bulge happened. One patient undergoing removal of all anterior and lateral abdominal wall had difficult defecation and urination during the first month after operation, and recovered through practising chest breathing. Ten patients developed fresh desmoids in other body positions postoperatively within 1-3 years, in whom 3 patients died of intestinal obstruction due to rapid neoplasm development and 7 patients survived with tumor receiving conservative therapy. All the 28 survival patients could restore normal life and workand have appropriate sports.

CONCLUSION

Radical resection and immediate reconstruction of giant myofascial defect using synthetic prosthesis for patients with giant desmoid in abdominal wall is safe and effective.

[China Guideline for Diagnosis and Treatment of Incisional Hernia (2018 edition)]

Abdominal incisional hernia is the result of the loss of the integrity and tension balance of the abdominal wall. According to clinical manifestation and physical examination, most incisional hernia can be clearly diagnosed. For small and concealed incisional hernia, the diagnosis can be confirmed by imaging examination. According to size of defect, it can be divided into small, middle, large, and giant incisional hernia. According to location of lesion, it can be divided into incisional hernia in the central or peripheral region of the anterior abdominal wall, in the lateral abdominal wall, and in the back. According to the presence of recurrence, it can be divided into primary and recurrent incisional hernia. Patients with definite diagnosis and suitable for surgical treatment after risk assessment are recommended for elective surgery. For patients who are not suitable for surgery, appropriate abdominal bandages are recommended to limit the development of incisional hernia. Surgical methods:(1) Simple suture repair is suitable for small incisional hernia; (2) Reinforcement repair using materials is recommended for middle incisional hernia or above; (3) When the materials are used in open repair, onlay and sublay methods are usually adopted. (4) IPOM or underlay methods are always adopted when materials are used for laparoscopic repair; (5) Hybrid repair is performed by combining open and laparoscopic techniques; (6) Methods to increase the abdominal cavity capacity include compartmental separation technology(CST) and lateral transverse abdominal muscle release technology (TAR); (7) Abdominal wall reconstruction with muscle fascial flap can be supplemented with mesh. According to the clinical practice of our country in the recent 4 years and based on "China Guideline for Diagnosis and Treatment of Incisional Hernia (2014 edition)", the " China Guideline for Diagnosis and Treatment of Incisional Hernia (2018 edition) " was completed after discussion and consultation with more than 50 experts and scholars in China. The definitions, etiology, pathophysiology, classification, diagnosis, differential diagnosis, treatment were comprehensively updated, and the viewpoints, measures and methods supported by evidence-based medicine were pointed out. The relevant medical institutions and surgeons in China are requested to carry out the guide according to actual clinical reference.

[A briefly discussion of the progress and development direction of incisional hernia surgery in China]

Since large-scale popularization of the surgical treatment of hernia in the 1990s, China has made great process in the field of hernia and abdominal wall surgery. In the treatment of incisional hernia of abdominal wall, a relatively complete system has been established in China, for instance, the formulation of guidelines, the purpose of incisional hernia treatment, the principle of surgical treatment, the choice of surgical methods, the improvement of material application, standardized treatment process, optimized management system. Common procedures of incisional hernia are open operations, including direct repair suture, bridging repair, and separation techniques of tissue construction. Meanwhile, the laparoscopic repair develops quickly in China as well. Compared with Western countries however, we still have a long way in overall level, for instance, treatment innovation, data integrity accumulation, quality control, technical innovation, new materials research, and monitoring of side-effects of implant materials. What we should consider and pay attention to is how to further develop hernia surgery and make it sustainable. Based on surgical experiences of incisional hernia in China, this paper intends to share the modern knowledge of incisional hernia and abdominal wall surgery.

[2017 hotspots review and future prospects of abdominal wall and hernia surgery]

Hernia and abdominal surgery keeps moving forward rapidly In 2017, lots of progress were achieved in etiology, material, and surgical technique. In etiology, TTN gene missense mutation was found in family members of indirect inguinal hernia. In material, a long-term slow-absorptive patch was present leading to a good choice of hernia therapy; application of 3D print for individual patch repair was expected. In surgical technique, efficacy of laparoscopic minimal invasive procedure or MILOS and eMILOS procedures was satisfactory in the treatment of complicated incisional hernia; tissue separation, patch placement and abdominal wall reconstruction by robotic surgery resulted in bigger operative space, faster postoperative recovery and lower morbidity of infection and seroma at operative site. In addition, there were more and more evidences to support that prophylactic use of patch in enterostomy can prevent the occurrence of postoperative parastomal hernia and incisional hernia. Domestic surgeons contributed mainly to the standardization of hernia surgery in 2017. This article reviews the hotspots of hernia and abdominal wall surgery in 2017, in the meantime, we prospect the progress in the near future.

[Postoperative ventral hernia - unsolved issues of surgical tactics]

Currently, there is no unified opinion on some problematic issues of surgical treatment of postoperative ventral hernias. Current approaches and surgical aspects of primary and recurrent postoperative ventral are reviewed in the article.

Integrating coupled magnetoelastic sensors onto a flexible hernia mesh for high dynamic range strain measurements

Despite better performance over primary repairs, tension-free ventral hernia repairs with mesh still suffer from a high recurrence rate. High stress gradients in the mesh are thought to contribute to hernia recurrence. We propose a postoperative monitoring system based on a coupled pair of magnetoelastic strain sensors to enable patients and physicians to non-invasively measure and track the strain distribution across the hernia mesh. Our design combines an encased resonator with a spring-loaded transducer to achieve high signal amplitude with a wide dynamic range. We also demonstrate a fabrication protocol to integrate the resonant strain sensors with a commercial polypropylene mesh. The packaged sensor is capable of detecting up to 37.5 millistrain, an order of magnitude greater than previously demonstrated.

Next Generation Mesh Fixation Technology for Hernia Repair

Laparoscopic ventral hernia repair (LVHR) remains a safe, reproducible, and popular method employed by surgeons to repair abdominal wall hernias. Patient selection, operative technique, instrumentation, and implant choice all remain surgeon dependent. Inherent in the technique is the option of using mesh. The decision of where to place the mesh and how to optimally fixate the mesh in the onlay, sublay, or intraabdominal positions also remain surgeon dependent and has been the subject of ongoing debates for the past two decades. In an ongoing effort to develop new methods for securing mesh to minimize pain without increased recurrence rates, novel mesh fasteners and mesh textiles have been developed. With increasing surgeon responsibility to improve value, surgeons should concentrate more on choosing the novel options that not only improve outcomes, but also reduce overall costs. This chapter reviews some of the emerging markets for these technologies.

Robotic Hernia Repair

The use of the da Vinci robot for inguinal and ventral hernia repair has exponentially increased over the last five years. This increase is occurring in spite of historical cost analyses showing robotic surgery to be cost prohibitive for other general surgery procedures. Specific data regarding outcomes and cost analysis for hernia is lacking. The increase in robotic hernia repairs is likely related to intangible factors such as enhanced visualization, articulating instruments, and hospital resources. Further study of robotic hernia repair is needed prospectively as its use increases to delineate the true benefits.

Laparoscopic Stapled Sublay Repair With Self-Gripping Mesh: A Simplified Technique for Minimally Invasive Extraperitoneal Ventral Hernia Repair

INTRODUCTION

Minimally invasive laparoscopic and robotic techniques for ventral hernia repair have evolved to achieve the benefits and minimize the limitations of both the open Rives-Stoppa sublay mesh repair and laparoscopic intraperitoneal onlay mesh (IPOM) repair. By combining the principles of a retromuscular repair with the benefits of a minimally invasive approach, these techniques attempt to decrease recurrence, increase functionality, exclude mesh from the viscera, limit infection and wound complications, and minimize pain. The difficult ergonomics, challenging dissection, and extensive suturing make traditional laparoscopic sublay repair technically challenging and has led to increased robotic utilization to overcome these limitations. We describe a laparoscopic extraperitoneal sublay mesh repair technique using an endoscopic stapler to facilitate reapproximation of the linea alba and creation of the retromuscular space, and self-gripping mesh to position and fixate the prosthetic.

MATERIALS AND METHODS

Between January and June 2016, 10 patients with midline ventral and incisional hernias underwent laparoscopic extraperitoneal stapled sublay mesh repair with self-gripping mesh. Three of these cases included a laparoscopic posterior component separation with myofascial release of the transversus abdominis muscle to facilitate midline closure. Intraoperative and perioperative complications, early recurrence, pain, and narcotic usage were measured.

RESULTS

There were no significant intraoperative complications or conversions to open surgery. Patients were discharged at 1.2 days on average. Early postoperative complications included a hernia site seroma in one patient, which resolved without intervention. There were no early postoperative infections or recurrences. Compared with traditional laparoscopic IPOM repair, there was less acute postoperative pain and use of analgesics.

CONCLUSIONS

Laparoscopic extraperitoneal stapled sublay mesh repair is a safe and effective method for the treatment of medium- to large-sized ventral and incisional hernias. This extraperitoneal stapled approach using self-gripping mesh facilitates a minimally invasive sublay repair and abdominal wall reconstruction using traditional laparoscopic tools.

A Clinical Quality Improvement (CQI) Project to Improve Pain After Laparoscopic Ventral Hernia Repair

Patients who undergo laparoscopic ventral hernia repair can have significant post-operative pain and discomfort from both somatic pain due to mesh fixation and visceral pain due to CO2 insufflation pressure. In an attempt to improve outcomes, a Clinical Quality Improvement (CQI) project was implemented by a multi-disciplinary hernia team. CQI tools were applied for consecutive patients who underwent laparoscopic ventral hernia repair from June 2012 through September 2015 (39 months). Initiatives for improved patient outcomes during this period included the administration of a transversus abdominis plane (TAP) block and/or an intra-operative block with long-acting local anesthetic first, and then a low pressure pneumoperitoneum (LPP) system was implemented later in the project. One-hundred-twenty patients who underwent a laparoscopic ventral/incisional hernia repair were included in the analysis. Fifty-three patients had no block and had conventional insufflation at 15 mmHg (No Block-No LPP group). Outcomes for this group included a median time in the Post-Anesthesia Care Unit (PACU) of 126 minutes, a median length of stay of 4.0 days, a median use of opioid morphine equivalents (MEQ) in the PACU of 10.0, and a total use of opioid MEQ for the entire hospital stay of 100.0. Thirty-seven patients had blocks with a long-acting local anesthetic and conventional insufflation at 15 mmHg (Block only group). Outcomes for this group showed improvement for all outcomes, but none were statistically significant. Thirty patients had blocks with a long-acting local anesthetic and a low pressure pneumoperitoneum system with a standard pressure of 8 mmHg. Outcomes for this group included a median time in PACU of 83.6 minutes, a median length of stay of 1.5 days, a median amount of opioid use in the PACU of 5.0 MEQ, and a median use of opioid use for the entire hospital stay of 26.0 MEQ. All of these outcomes were statistically significant improvements compared with the No Block-No LPP and Block only groups. Implementation of a CQI program, including long-acting local anesthetic blocks and a low pressure pneumoperitoneum system as part of a multi-modal pain strategy for patients who underwent laparoscopic ventral hernia repair, was associated with decreased PACU time, decreased length of stay, and less opioid use in the PACU and for the entire hospital stay.

Towards a full-field strain sensor for guiding hernia repairs

Each year, approximately 400,000 ventral hernia repairs are performed in the United States [1], [2]. Large ventral hernias (hernias that occur in the abdominal wall) are typically treated by suturing in a surgical mesh to cover and overlap the hernia defect. However, in 10-20% of patients, the hernia repair fails, resulting in recurrence of the hernia, along with other complications including infection and intestinal obstruction [3], [4]. One potential cause of hernia recurrence is the unequal distribution of stress across the mesh resulting in high stress concentrations at the tissue-mesh interface, particularly at the site of mesh fixation to the abdominal wall muscles[5], [6]. Strain across the mesh can be used as an indicator for how evenly stress is distributed across the surface of the mesh. To this end, we have built a full-field, 3D strain measurement system to enable physicians to actively identify and address areas of high strain during the surgery, thus decreasing the rate of hernia recurrence. The strain sensor uses an optical technique, called the grid method, in conjunction with the defocused particle image velocimetry (DPIV) technique to measure the 3D strain distribution across the mesh. The system can achieve a limit of detection down to 0.4% strain and across a 50 cm range z-axis displacement using a Canon EOS 7D camera with a pinhole aperture mask.

[Surgical treatment of large incisional hernia]

Treatment of large incisional hernia (LIH) is still a challenge to most of the abdominal wall surgeons. Mesh reinforcement is essential for treatment of LIH, component separation technique(CST) provides significant assistances for the close of abdominal wall defect. The use of mesh reinforcement with CST during LIH repair displayed the best results. Understanding and choosing the correct procedure is very important for LIH repair which significantly decreases both the recurrence rate and morbidity postoperatively after LIH repair.

Rare variant of inguinal hernia, interparietal hernia and ipsilateral abdominal ectopic testis, mimicking a spiegelian hernia. Case report

We report a case in which the combination of an interparietal inguinal hernia and ipsilateral ectopic testicle mimicked a spigelian hernia. The patient was a 22-day-old boy who presented with a reducible mass that extended from the right lumbar region to the iliac fossa region. The right testis was palpable in the right lumbar region. Ultrasonography and magnetic resonance imaging revealed that a small bowel had herniated through the inguinal region below the external oblique aponeurosis. Surgery was performed when the patient was 23 months old. Laparoscopic examination to identify the hernia orifice revealed that it was the deep inguinal ring, and the testicular vessels and the vas deferens passed beneath the hernia sac. An inguinal incision was made, and a hernia sac was observed passing through the deep inguinal ring and extending superiorly below the aponeurosis. The testis was found in the hernia sac. Traditional inguinal herniorrhaphy and traditional orchidopexy were performed, and the postoperative course was uneventful. It is difficult to understand the surgical anatomy of interparietal hernias, but once the surgical anatomy is understood, surgical repair is simple. We report the case with a review of the literature and also emphasize that laparoscopic exploration is helpful during surgery.

Incisional hernia recurrence through genomic profiling: a pilot study

PURPOSE

Although situational risk factors for incisional hernia formation are known, the methods used to determine who would be most susceptible to develop one are unreliable. We hypothesized that patients with recurrent incisional hernias may possess unique gene expression profiles.

METHODS

Skin and intact fascia were collected from 15 normal control (NC) patients with no hernia history and 18 patients presenting for recurrent incisional hernia (RH) repair. Microarray analysis was performed using whole genome microarray chips on NC (n = 8) and RH (n = 9). These samples were further investigated using a pathway-specific PCR array containing fibrosis-related genes.

RESULTS

Microarray data revealed distinct differences in the gene expression profiles between RH and NC patients. One hundred and sixty-seven genes in the skin and 7 genes in the fascia were differentially expressed, including 8 directly involved in collagen synthesis. In particular, GREMLIN1, or bone morphogenetic protein antagonist 1, was under expressed in skin (fold = 0.49, p < 10(-7), q = 0.0009) and fascia (fold = 0.23, p < 10(-4), q = 0.095) of RH patients compared with NC. The PCR array data supported previous reports of decreased collagen I/III ratios in skin of RH versus NC (mean = 1.51 ± 0.73 vs. mean = 2.26 ± 0.99; one-sided t test, p = 0.058).

CONCLUSION

To our knowledge, this is the first microarray-based analysis to show distinct gene expression profiles between the skin and fascia of RH and NC patients and the first report of an association between GREMLIN1 and incisional hernia formation. Our results suggest that gene expression profiles may act as surrogate markers that stratify patients into different groups at risk for hernia development prior to their initial surgery.

Ambulatory surgery of umbilical, epigastric and small incisional hernias: open preperitoneal flat mesh technique in local anaesthesia

Introduction. The dilemma whether to use the mesh or non mesh technique in the management of umbilical, epigastric and small incisional hernia is slowly fading away. The open preperitoneal "flat mesh" technique performed as ambulatory surgery may be one of the solutions. The Aim. The aim of this retrospective study is to present the results of open preperitoneal "flat mesh" technique in the management of umbilical, epigastric and small incisional hernia within Material and methods. This study included 34 patients (11 of them with umbilical, 13 with epigastric and 8 of them with small incisional hernia) operated by one surgeon in the period January 2004 - January 2006. Results. The median operative time was 52 minutes for umbilical hernia?s, 43 minutes for epgastric and 54 minutes for incisional hernia?s. The ambulatory surgery was performed at 91% of patients. The median hospitalization was 4h for patients with umbilical hernia?s, 3,7h for patients with epigastric and, 7,7h for patients with small incisional hernia. The follow up is 10,5 months. Apart of one superficial infection other complications were absent. Conclusion. The open preperitoneal "flat mesh" technique performed in local anesthesia as an ambulatory surgery provides good results in the management of umbilical, epigastric and small incisional hernia.