Intra-abdominal hypertension and compartment syndrome after complex hernia repair.

PURPOSE: Abdominal compartment syndrome (ACS) is a well-known concept after trauma surgery or after major abdominal surgery in critically ill patients. However, ACS as a complication after complex hernia repair is considered rare and supporting literature is scarce. As complexity in abdominal wall repair increases, with the introduction of new tools and advanced techniques, ACS incidence might rise and should be carefully considered when dealing with complex abdominal wall hernias. In this narrative review, a summary of the current literature will highlight several key features in the diagnosis and management of ACS in complex abdominal wall repair and discuss several treatment options during the different steps of complex AWR. METHODS: We performed a literature search across PubMed using the search terms: "Abdominal Compartment syndrome," "Intra-abdominal pressure," "Complex abdominal hernia," and "Ventral hernia." Articles corresponding to these search terms were individually reviewed by primary author and selected on relevance. CONCLUSION: Intra-abdominal hypertension (IAH) and ACS require imperative attention and should be carefully considered when dealing with complex abdominal wall hernias, even without significant loss of domain. Development of a true abdominal compartment syndrome is relatively rare, but is a devastating complication and should be prevented at all cost. Current evidence on surgical treatment of ACS after hernia repair is scarce, but conservative management might be an option in the early phase and low grades of IAH. However, life-saving treatment by relaparotomy and open abdomen management should be initiated when ACS starts setting in.

Anterior versus posterior component separation technique for advanced abdominal wall reconstruction: a proposed algorithm.

OBJECTIVE: The precise indications for employing the anterior component separation technique (ACST) and the Transversus Abdominis Release (TAR) in abdominal wall reconstruction (AWR) remain uncertain, despite the undeniable value of both techniques. The aim of this study was to analyze the anterior fascial closure rate, postoperative wound morbidity, and hernia recurrence rate for both procedures according to the algorithm used for complex AWR. METHODS: A retrospective analysis of prospectively collected data was carried out. Patients undergoing AWR for midline incisional hernias using either open or endoscopic ACST (E-ACST) or TAR between March 2013 and August 2022 were included. Patients with lateral hernia components were excluded. The surgical technique was depending on the pre- and intraoperative findings regarding hernia width and on the estimated traction to achieve anterior fascial closure (see algorithm). Initially, intermediate hernia defects ranging from approximately 10-14 cm in width were repaired using E-ACST. However, as the study advanced, TAR became the preferred method for addressing these types of defects. Open ACST was consistently employed for defects wider than 14-15 cm throughout the entire study duration. Outcomes of interest were anterior fascial closure, surgical site occurrences, and hernia recurrence rate. Follow-up was performed at 1 month, 1 year, and 2 years. RESULTS: A total of 119 patients underwent AWR with CST: 63 patients (52.9%) were included in the ACST group and 56 patients (47.1%) in the TAR group. No significant differences were observed in patient and hernia characteristics. The use of botulinum toxin A (BTA) injection and preoperative progressive pneumoperitoneum (PPP) was more frequently used in the ACST group (BTA 19.0%, PPP 15.9% versus BTA 5.4%, PPP 1.8% for TAR patients). Anterior fascial closure was achieved in 95.2% of the ACST group and 98.2% of the TAR group (p = 0.369). The TAR group demonstrated a significantly lower SSO rate at one month (44.3% versus 14.3%, p < 0.001) and required fewer procedural interventions (SSO-PI) (31.1% versus 8.9%, p = 0.003). The recurrence rate at one year was low and there was no statistically significant difference between the two groups (ACST 1.8% vs TAR 4.5%, p = 0.422). CONCLUSION: Following a proposed algorithm, the anterior fascial closure rate was high and similar for both techniques. As postoperative wound morbidity is significantly increased after ACST, our findings support recommending TAR for defects up to 14 cm in width, while favoring open ACST for larger defects.

Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach?

PURPOSE: Ventral hernia repair has become a common procedure, but the way in which it is performed still depends on surgeon's skill, experience, and habit. The initial open approach is faced with extensive dissection and a high risk of infection and prolonged hospital stay. To tackle these problems, minimally invasive procedures are gaining interest. Several new techniques are emerging, but laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. We will discuss why laparoscopic IPOM is still a valuable approach in the treatment of primary non-complicated midline hernias and review the current literature. METHODS: We performed a literature search across PubMed and MEDLINE using the following search terms: "Laparoscopic hernia repair", "Ventral hernia repair" and "Primary ventral hernia". Articles corresponding to these search terms were individually reviewed by the primary author and selected on relevance. CONCLUSION: Laparoscopic IPOM still is a good approach for the efficient treatment of primary non-complicated midline hernias. Several techniques are emerging, but are faced with increased costs, technical difficulties, and low study patient volume. Further research is warranted to show superiority and applicability of these new techniques over laparoscopic IPOM, but until then laparoscopic IPOM should remain the go-to technique.

Late Occurring Medial Migration of a Lag Screw in Gamma Nailing.

An 81-year-old female was treated for a pertrochanteric multifragmentary fracture of the proximal femur with a third-generation Gamma nail. After 3 months she presented herself again with acute pain and inability to bear weight on the leg. Radiographs showed medial migration of the lag screw. She was treated with a total hip arthroplasty, after which she was successfully discharged. In this case report the possible causes of this late and unusual complication are discussed.

Postoperative Inflammatory Response in Crohn's Patients: A Comparative Study.

BACKGROUND AND AIMS: Surgery for Crohn's disease [CD] can be complicated by an enhanced inflammatory response. This retrospective study aims to compare the inflammatory response measured by C-reactive protein [CRP] in patients operated for CD with patients undergoing similar surgery for colorectal cancer [CRC]. METHODS: All CD patients undergoing an ileocaecal resection between February 2001 and December 2013 were retrieved from a prospectively maintained database. The same number of patients with a CRC of the ascending colon, undergoing a laparoscopic right hemicolectomy between March 2009 and June 2014, were retrieved from a CRC database. CRP level during the first 7 postoperative days was used as primary outcome. RESULTS: Totals of 112 consecutive CD patients (male 40.2%; median age: 32.3 yrs; interquartile range [IQR]: 25.2-45.1) and 112 consecutive CRC patients [male 53.6%; median age 71.6 yrs; IQR: 64.7-77.5] were included. Postoperative CRP level in the CD group was on average 27% higher compared with the CRC group [p = 0.02]. The day-specific differences in CRP values were 21% (p = 0.021, 95% confidence interval [CI]: 3% 41%), 41% [p = 0.005, 95% CI: 11%-79%], 49% [p = 0.007, 95% CI: 11%-96%], and 49% [p = 0.006, 95% CI: 12%-100%] higher for CD patients at Days 1, 4, 5, and 6 respectively. The difference in postoperative CRP level was partially due to differences in preoperative CRP level. CONCLUSION: CD patients develop a higher postoperative CRP level, probably reflecting an enhanced postoperative inflammatory response, which may be triggered by a higher preoperative inflammatory state.