Effects of botulinum toxin in two indicators of loss of domain and hernia size among patients with large ventral hernias.

BACKGROUND: In patients with large ventral hernias, botulinum toxin to external and internal oblique muscles decreases thickness and increases length. We examined the impact of botulinum toxin in the amount of loss of domain according to two ratios and in hernia size. METHODS: Between October 2021 and November 2023, 20 patients with ventral hernias measuring 10 cm or more on the horizontal size underwent the administration of 50 units of botulinum toxin to each external and each internal oblique muscle 4 weeks before their surgery. Incisional hernia volume to peritoneal volume ratio, volume ratio, and hernia size were compared before and 4 weeks after the injection of botulinum toxin. Comparisons between all variables obtained before and after the administration of botulinum toxin were performed using either the paired t-test or the Wilcoxon signed-rank test. Pearson correlation coefficient was used to analyze associations between initial conditions and further changes observed after botulinum toxin injection. RESULTS: We observed a 42% reduction in muscle amplitude, 16% increase in intra-abdominal volume, 28% decrease in herniated volume, decreases of 6% in IHV/PV ratio and of 11% in V ratio, 11% reduction of hernia width, and decrease of 10% in rectangular and elliptical hernia areas. CONCLUSIONS: In patients with large ventral hernias, botulinum toxin is associated with reduction of hernia size and decrease in loss of domain, the latter not being significant when less than 10% of the visceral block is herniated.

[Surgical treatment of complex incisional hernia]. / Khirurgicheskoe lechenie patsientov so slozhnoi posleoperatsionnoi ventral'noi gryzhei.

There is no generally accepted incisional hernia classification. To categorize incisional hernias, the European Hernia Society (EHS) proposed their classification based on the measurement of three parameters - location, dimension of hernia gate and recurrence. Unfortunately, this classification does not consider the «loss of the domain¼ of 20% or more, local complications including trophic ulcer or fistula of anterior abdominal wall. Moreover, implantation of mesh after previous hernia repair, obesity and other clinical factors are also not considered. Thus, surgeons have recently allocated patients with complex incisional hernia in a separate group. There is no clear definition of this term. There are no clinical guidelines on the management of patients with these hernias, and the choice of optimal surgical treatment remains individual. The authors present a patient with complex incisional hernia. Surgical strategy is described.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes.

BACKGROUND: While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS: Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS: A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION: For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature.

With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.

Retro-rectus placement of bio-absorbable mesh improves patient outcomes.

BACKGROUND: There is little consensus on the ideal anatomical placement of bio-absorbable mesh. We hypothesized that retro-rectus placement of bio-absorbable mesh would significantly reduce recurrence rates when compared to intraperitoneal mesh placement. METHODS: A retrospective review was conducted of patients who underwent open complex ventral hernia repair using bio-absorbable mesh (Bio-A, Gore, Flagstaff, AZ). Patient demographics and Centers for Disease Control wound type were collected. RESULTS: A total of 81 patients were included. Seventy-four (91.4%) of these hernia repairs had mesh in the retro-rectus position, while 7 (8.6%) had intraperitoneal mesh placement. Patient demographics, including preoperative comorbidities, did not differ between groups. The retro-rectus group trended to have larger hernia defects (156.2 cm2) compared to the intraperitoneal group (63.9 cm2) (p = 0.058). Overall complications (e.g., dehiscence, wound drainage, cellulitis, sepsis) were also similar in both groups of patients. Recurrence rates in the retro-rectus and intraperitoneal group were 8.1% and 42.9%, respectively (p = 0.005). When evaluating only patients with CDC class 1 wounds, the recurrence rate in the retro-rectus group was 8.2% and the intraperitoneal group was 50% (p = 0.02). Overall, the average patient follow-up was 22 months and did not differ between groups. Both the retro-rectus and intraperitoneal groups indicated a significant (p < 0.05) improvement in quality of life from baseline. No long-term (> 7 days) antibiotics were used and no mesh implants were removed during the study. CONCLUSION: Patients who underwent open complex ventral hernia repairs with bio-absorbable mesh in the retro-rectus position experienced lower overall complication rates than those with intraperitoneal mesh placement. Despite a larger hernia defect in the retro-rectus group, recurrence rates were significantly reduced with retro-rectus placement of mesh compared to intraperitoneal placement. In addition, recurrence rates using bio-absorbable mesh in clean wounds are comparable to previously published recurrence rates with permanent mesh.

Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia.

INTRODUCTION: Operative management of complex ventral hernia still remains a significant challenge for surgeons. Closure of large defects in the unprepared abdomen has serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. We report outcomes of 56 consecutive patients who had preoperative Botulinum toxin A (BTA) abdominal wall relaxation facilitating closure and repair. METHODS: This was a prospective observational study of 56 patients who underwent ultrasound-guided BTA into the lateral abdominal oblique muscles prior to elective ventral hernia repair between November 2012 and January 2017. Serial non-contrast abdominal CT imaging was performed to evaluate changes in lateral oblique muscle length and thickness. All hernias were repaired laparoscopically, or laparoscopic-open-laparoscopic (LOL) using intraperitoneal onlay mesh. RESULTS: 56 patients received BTA injections at predetermined sites to the lateral oblique muscles, which were well tolerated. Mean patient age was 59.7 years, and mean BMI was 30.9 kg/m2 (range 21.8-54.0). Maximum defect size was 24 × 27 cm. A subset of 18 patients underwent preoperative pneumoperitoneum as an adjunct procedure. A comparison of pre-BTA to post-BTA imaging demonstrated an increase in mean lateral abdominal wall length from 16.1 cm to 20.1 cm per side, a mean gain of 4.0 cm/side (range 1.0-11.7 cm/side) (p < 0.0001). This corresponds to an unstretched mean length gain of 8.0 cm of the lateral abdominal wall. Laparoscopic/LOL primary closure was achieved in all cases, with no clinical evidence of raised intra-abdominal pressures. One patient presented with a new fascial defect 26 months post-operative. CONCLUSION: Preoperative BTA to the lateral abdominal wall muscles is a safe and effective technique for the preparation of patients prior to operative management of complex ventral hernias. BTA temporary flaccid paralysis relaxes, elongates and thins the chronically contracted abdominal musculature. This in turn reduces lateral traction forces facilitating laparoscopic repair and fascial closure of large defects under minimal tension.

Complex abdominal wall reconstruction in the setting of active infection and contamination: a systematic review of hernia and fistula recurrence rates.

AIM: Minimal evidence exists to guide surgeons on the risk of complications when performing abdominal wall reconstruction (AWR) in the presence of active infection, contamination or enterocutaneous fistula. This study aims to establish the outcomes of contaminated complex AWR. METHOD: Analysis was conducted according to PRISMA guidelines. Systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on single-staged repair of contaminated complex AWR were included. Pooled data were analysed to establish rates of complications. RESULTS: Sixteen studies were included, consisting of 601 contaminated complex AWRs, of which 233 included concurrent enterocutaneous fistula repair. The average follow-up period was 26.7 months. There were 146 (24.3%) reported hernia recurrences. When stratified by repair method, suture repair alone had the lowest rate of recurrence (14.2%), followed by nonabsorbable synthetic mesh reinforcement (21.2%), biological mesh (25.8%) and absorbable synthetic mesh (53.1%). Hernia recurrence was higher when fascial closure was not achieved. Of the 233 enterocutaneous fistula repairs, fistula recurrence was seen in 24 patients (10.3%). Suture repair alone had the lowest rate of recurrence (1.6%), followed by nonbiological mesh (10.3%) and biological mesh reinforcement (12%). Forty-six per cent of patients were reported as having a wound-related complication and the mortality rate was 2.5%. CONCLUSION: It is feasible to perform simultaneous enterocutaneous fistula repair and AWR as rates of recurrent fistula are comparable with series describing enterocutaneous fistula repair alone. Hernias recurred in nearly a quarter of cases. This analysis is limited by a lack of comparative data and variability of outcome reporting.

Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia.

BACKGROUND: Repair of complex ventral hernia can be very challenging for surgeons. Closure of large defects can have serious pathophysiological consequences. Botulinum toxin A (BTA) has recently been described to provide flaccid paralysis to abdominal muscles prior to surgery, facilitating closure and repair. METHODS: This was a prospective observational study of 32 patients who underwent ultrasound-guided injections of BTA to the lateral abdominal wall muscles prior to elective repair of complex ventral hernia between January 2013 and December 2015. Serial non-contrast abdominal CT imaging was performed to measure changes in fascial defect size, abdominal wall muscle length and thickness. All hernias were repaired laparoscopically or laparoscopic-assisted with placement of intra-peritoneal mesh. RESULTS: Thirty-two patients received BTA injections which were well tolerated with no complications. A comparison of baseline (preBTA) CT imaging with postBTA imaging demonstrated an increase in mean baseline abdominal wall length from 16.4 to 20.4 cm per side (p < 0.0001), which translates to a gain in mean transverse length of the unstretched anterolateral abdominal wall muscles of 4.0 cm/side (range 0-11.7 cm/side). Fascial closure was achieved in all cases, with no instances of raised intra-abdominal pressures or its sequelae, and there have been no hernia recurrences to date. CONCLUSIONS: Preoperative BTA injection to the muscles of the anterolateral abdominal wall is a safe and effective technique for the preoperative preparation of patients prior to laparoscopic mesh repair of complex ventral hernia. This technique elongates and thins the contracted and retracted musculature, enabling closure of large defects.

Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair.

BACKGROUND: A rarely used technique for enabling closure of large ventral hernias with loss of domain is preoperative progressive pneumoperitoneum (PPP), which uses intermittent insufflation to gradually stretch the contracted abdominal wall muscles, increasing the capacity of the abdominal cavity. This allows the re-introduction of herniated viscera into the abdominal cavity and assists in closure of giant hernias which may otherwise be considered inoperable. METHODS: This was a prospective study assessing 16 patients between 2013 and 2015 with multi-recurrent ventral hernia. All patients were treated preoperatively with both Botulinum Toxin A (BTA) injections to the lateral abdominal wall muscles to confer flaccid paralysis, and short-term PPP to passively expand the abdominal cavity. All patients underwent serial abdominal CT imaging, with pre- and post-treatment circumference measurements of the peritoneal cavity and hernia sac, prior to undergoing operative mesh repair of their hernia. RESULTS: The mean hernia defect size was 236 cm2, with mean 28 % loss of domain. The mean overall duration of PPP was 6.2 days. The mean gain in abdominal circumference was 4.9 cm (5.6 %) (p 0.002) after BTA and PPP. Fascial closure and mesh hernia repair were performed in all 16 patients, with no patients suffering from postoperative abdominal hypertension, ventilatory impairment, or wound dehiscence. There are no hernia recurrences to date. Eight patients (50 %) experienced PPP-related complications, consisting of subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumocardium, and metabolic acidosis. No complication required intervention. CONCLUSIONS: PPP is a useful adjunct in the repair of complex ventral hernia. It passively expands the abdominal cavity, allowing viscera to re-establish right of domain. At the same time, it helps to minimize the risks of postoperative abdominal compartment syndrome and the sequelae of fascial closure under tension. However, its benefits must be carefully weighed with the risk of serious complications, such as infection, perforation, pneumothorax, and pneumomediastinum.

Long-term outcomes of sandwich ventral hernia repair paired with hybrid vacuum-assisted closure.

BACKGROUND: Sandwich ventral hernia repair (SVHR) may reduce ventral hernia recurrence rates, although with an increased risk of surgical site occurrences (SSOs) and surgical site infections (SSIs). Previously, we found that a modified negative pressure wound therapy (hybrid vacuum-assisted closure [HVAC]) system reduced SSOs and SSIs after ventral hernia repair. We aimed to describe our outcomes after SVHR paired with HVAC closure. METHODS: We conducted a 4-y retrospective review of all complex SVHRs (biologic mesh underlay and synthetic mesh overlay) with HVAC closure performed at our institution by a single surgeon. All patients had fascial defects that could not be reapproximated primarily using anterior component separation. Descriptive statistics were used to report the incidence of postoperative complications and hernia recurrence. RESULTS: A total of 60 patients (59.3 ± 11.4 y, 58.3% male, 75% American Society of Anesthesiologists class ≥3) with complex ventral hernias being underwent sandwich repair with HVAC closure. Major postoperative morbidity (Dindo-Clavien class ≥3) occurred in 14 (23.3%) patients, but incidence of SSO (n = 13, 21.7%) and SSI (n = 4, 6.7%) was low compared with historical reports. Median follow-up time for all patients was 12 mo (interquartile range 5.8-26.5 mo). Hernia recurrence occurred in eight patients (13.3%) after a median time of 20.6 months (interquartile range 16.4- 25.4 months). CONCLUSIONS: Use of a dual layer sandwich repair for complex abdominal wall reconstruction is associated with low rates of hernia recurrence at 1 year postoperatively. The addition of the HVAC closure system may reduce the risk of SSOs and SSIs previously reported with this technique and deserves consideration in future prospective studies assessing optimization of ventral hernia repair approaches.

Peritoneal flap technique for abdominal wall expansion in the management of complex ventral hernias: a multicentre study from India.

INTRODUCTION: Large abdominal wall hernias often require techniques for wall expansion to improve surgical outcomes. The peritoneal flap hernioplasty (PF) is one such technique that utilizes the hernia sac to reconstruct the abdominal wall, however, with limited published data. It is a modification of the Rives-Stoppa mesh repair where a part of the bisected hernia sac is utilized to reconstruct the anterior fascia and the other part for the posterior fascia. We present a collated retrospective analysis of the outcomes from three centers performing PF with or without transverse abdominis release (TAR) in patients with complex ventral hernias. METHODS: The PF was performed in patients with incisional hernias, both midline and lateral. The primary outcome measured was hernia recurrence. The secondary outcomes were to evaluate pain, surgical site infection, seroma, hematoma, wound dehiscence, pseudo-recurrence, Clavien-Dindo score for complications, and the patient's reported quality of life. The quality of life was assessed by oral questionnaires in the follow-up period. RESULTS: We analyzed 63 patients (38 female, 25 male) with a mean width of hernia defect of 11 cm SD 4. Based on the European Hernia Society (EHS) classification 42 patients were W3 and 21 were W2 hernias. Fifty patients had a midline hernia, while the rest of the patients included transverse, subcostal, and rooftop incision hernias. The classical peritoneal flap procedure was done in 29 (46%) patients, while the peritoneal flap with TAR was done in 34 (54%) patients. Four patients had symptomatic seroma (6%), seven superficial surgical site infection (SSI) (11%), one deep SSI (1.5%), one skin necrosis (1.5%), and one anterior peritoneal flap necrosis (1.5%). No patient required postoperative ventilatory support. The mean pain score on day one was 3/10. There was no recurrence in the mean follow-up of 17 months (range 5 to 49 months). Overall, 58 of 63 (92%) patients reported being satisfied with their surgery. CONCLUSION: In our multicentre study, we found the PF technique with or without TAR for midline and non-midline ventral hernia leads to satisfactory outcomes in terms of low recurrence, low rate of complications, and a good quality of life in the medium to long term. It appears to be a useful technique in the surgeon's armamentarium to repair W2 and W3 hernias needing expansion of abdominal domain.

Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release).

BACKGROUND: Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR. METHODS: This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36 months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score. RESULTS: The average follow-up was 38.3 ± 12.7 months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery. CONCLUSIONS: This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.

Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure.

PURPOSE: Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. METHOD: A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. RESULTS: Imaging post-BTA revealed hernia width reduction of 1.9 cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1 cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. CONCLUSION: BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

Outcomes after open posterior component separation via transversus abdominis release (TAR) for incisional hernia repair. A systematic review and meta-analysis.

PURPOSE: Given its potential advantages, open Transversus Abdominis Release (oTAR) has been proposed as a durable solution for complex AWR. However, its applicability in different scenarios remains uncertain. We aimed to analyze the current available evidence and determine surgical outcomes after oTAR. METHODS: We performed a systematic electronic search on oTAR in PubMed/Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Postoperative morbidity and recurrence rates were included as primary endpoints and Quality of life (QoL) was included as secondary endpoint. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) between all studies. RESULTS: A total of 22 studies with 4,910 patients undergoing oTAR were included for analysis. Mean hernia defect and mesh area were 394 (140-622) cm2 and 1065 (557-2206) cm2, respectively. Mean follow-up was 19.7 (1-32) months. The weighted pooled proportion of recurrence, overall morbidity, surgical site occurrences (SSO), surgical site infection (SSI), surgical site occurrences requiring procedural intervention (SSOPI), major morbidity and mortality were: 6% (95% CI, 3-10%), 34% (95% CI, 26-43%), 22% (95% CI, 16-29%), 11% (95% CI, 8-16%), 4% (95% CI, 3-7%), 6% (95% CI, 4-10%) and 1% (95% CI, 1-2%), respectively. A significant improvement in QoL after oTAR was reported among studies. CONCLUSION: Open TAR is an effective technique for complex ventral hernias as it is associated with low recurrence rate and a significant improvement in QoL. However, the relatively high morbidity rates observed emphasize the necessity of further patients' selection and optimization to improve outcomes.

Use of botulinum toxin type A in the prehabilitation of abdominal wall musculature for hernia repair: a consensus proposal.

The prehabilitation of the abdominal wall through the infiltration of botulinum toxin type A, which induces temporary chemical denervation ("chemical component separation") in the lateral abdominal musculature, is a common practice in units specialized in abdominal wall surgery. However, its use for this indication is currently off-label. The main objective of this article is to describe a consensus proposal regarding indications, contraindications, dosages employed, potential side effects, administration method, and measurement of possible outcomes. Additionally, a proposal for an informed consent document endorsed by the Abdominal Wall Section of the Spanish Association of Surgeons is attached.

Preoperative Abdominal Muscle Elongation Facilitated Laparoscopic Intraperitoneal Onlay Mesh Repair of Complex Ventral Hernia.

Background: Complex ventral hernia remains a challenging situation for any surgeon. In this study, our aim was to analyze the effect of laparoscopic intraperitoneal onlay mesh (IPOM) repair in the treatment of complex abdominal wall hernia, with the assistance of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA). Methods: In this retrospective study, we included 13 patients with complex ventral hernia between May 2021 and December 2022. All patients undergoing PPP and BTA protocol before hernia repair. The length of abdominal wall muscles and abdominal circumference were measured from CT scan. All hernias were repaired with laparoscopic or laparoscopic-assisted IPOM. Results: Thirteen patients received PPP and BTA injections. PPP and BTA administration time was over 8.8 ± 2.5 days. Before and after PPP and BTA, imaging showed that the length of lateral muscle on each side increased from 14.3 to 17.4 cm (P < .05). The abdominal circumference increased from 81.8 to 87.9 cm (P < .05). Complete fascial closure was obtained in 13 patients (100%), and no patient experienced postoperative abdominal hypertension and ventilatory support. No patient suffered from recurrent hernia to date. Conclusions: Preoperative PPP combined with BTA injection plays a role similar to component separation technique, avoids the abdominal hypertension after laparoscopic IPOM repair of complex ventral hernia.

Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction.

BACKGROUND: Patients often need admission at an Intensive Care Unit (ICU), immediately after complex abdominal wall reconstruction (CAWR). Lack of ICU resources requires adequate patient selection for a planned postoperative ICU admission. Risk stratification tools like Fischer score and Hernia Patient Wound (HPW) classification may improve patient selection. This study evaluates the decision-making process in a multidisciplinary team (MDT) on justified ICU admissions for patients after CAWR. METHODS: A pre-Covid-19 pandemic cohort of patients, discussed in a MDT and subsequently underwent CAWR between 2016 and 2019, was analyzed. A justified ICU admission was defined by any intervention within the first 24 h postoperatively, considered not suitable for a nursing ward. The Fischer score predicts postoperative respiratory failure by eight parameters and a high score (> 2) warrants ICU admission. The HPW classification ranks complexity of hernia (size), patient (comorbidities) and wound (infected surgical field) in four stages, with increasing risk for postoperative complications. Stages II-IV point to ICU admission. Accuracy of the MDT decision and (modifications of) risk-stratification tools on justified ICU admissions were analyzed by backward stepwise multivariate logistic regression analysis. RESULTS: Pre-operatively, the MDT decided a planned ICU admission in 38% of all 232 CAWR patients. Intra-operative events changed the MDT decision in 15% of all CAWR patients. MDT overestimated ICU need in 45% of ICU planned patients and underestimated in 10% of nursing ward planned patients. Ultimately, 42% went to the ICU and 27% of all 232 CAWR patients were justified ICU patients. MDT accuracy was higher than the Fischer score, HPW classification or any modification of these risk stratification tools. CONCLUSION: A MDT's decision for a planned ICU admission after complex abdominal wall reconstruction was more accurate than any of the other risk-stratifying tools. Fifteen percent of the patients experienced unexpected operative events that changed the MDT decision. This study demonstrated the added value of a MDT in the care pathway of patients with complex abdominal wall hernias.

Long-term outcomes of Madrid approach after TAR for complex abdominal wall hernias: a single-center cohort study.

PURPOSE: Undeniably, in the last 2 decades, surgical approaches in the field of abdominal wall repair have notably improved. However, the best approach to provide a durable repair with low morbidity rate has yet to be determined. The purpose of this study is to outline our long-term results following the Transverse Abdominis Release (TAR) approach in patients with complex ventral hernias, focusing on the incidence of recurrence and overall patient satisfaction following surgery. METHODS: This is a retrospective study on 167 consecutive patients who underwent TAR between January 2015 and December 2021 for primary or recurrent complex abdominal hernias. Of these, 117 patients who underwent the open Madrid approach with the use of a double mesh (absorbable and permanent synthetic mesh) were selected and analyzed. A quality of life questionnaire (EuraHS QoL) comparing the preoperative and the postoperative status was administered. RESULTS: Between January 2015 and December 2021, we successfully treated 117 patients presenting with complex ventral defects using the double mesh technique (absorbable and permanent synthetic mesh). Of these, 26 (22.2%) were recurrent cases. At a median follow-up period of 37.7 months, there had been 1 (0.8%) case of recurrence and 8 cases (6.8%) of bulging. The QoL score was significantly improved when compared to the preoperative status in terms of cosmesis, body perception, and physical discomfort. CONCLUSIONS: The Madrid approach for posterior component separation is associated with both a low perioperative morbidity and recurrence rate. In accordance with other studies, we demonstrated that the TAR with reconstruction according to the Madrid approach provides excellent results in the treatment of complex abdominal wall hernias, even at long-term follow-up.

Posterior component separation with TAR: lessons learned from our first consecutive 52 cases.

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39-76) and Body mass index (BMI kg/m2) of 31.2 (24-45). More than half of patients (58%) were active smokers. Mean defect width was 13.6 cm (range 6-30) and mean defect area was about 267.9 cm2. Mean operative time was 228 min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7 days. 27% of patients developed minor complications (Clavien-Dindo grade I-II) and one case (1.9%) major complication (Clavien-Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28 months. In Univariate analysis Bio-A surface > 600 cm2 and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600 cm2 was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien-Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients.

Tanaka score predicts surgical intensive care admission following abdominal wall reconstruction.

PURPOSE: With the advancement of abdominal wall reconstruction, more complex hernia patients are undergoing repairs that may require a postoperative surgical intensive care unit (SICU) admission. The volume ratio (VR) of the hernia sac to the abdominal cavity is an easily applied method to quantify disease severity and the ensuing physiologic insult. This study aimed to predict postoperative SICU admission using VR and other preoperative variables. METHODS: A single-center retrospective review was conducted for patients undergoing large abdominal hernias (width ≥ 18 cm) repaired from September 2014 to October 2019. Patient demographics, comorbidities, abdominal surgical history, and VR were analyzed through univariate and multivariable methods to identify predictors of SICU admission within the first two postoperative days. A predictive model was generated and validated. RESULTS: Of 434 patients meeting inclusion criteria, 127(29%) required a SICU admission within the first two postoperative days. VR was significantly higher in SICU patients (Median 30.6% [IQR 14.4-59.0] vs. 10.6% [IQR 4.35-23.6], P < 0.001). Male sex, history of chronic obstructive pulmonary disease, prior component separation, recurrent incisional hernia, hernia grade 3, and VR showed higher odds of SICU admission. When validated on a testing dataset, these variables showed strong SICU admission predictions, with an area under the curve, sensitivity, and specificity of 0.82, 81.7% and 68.5%, respectively. CONCLUSIONS: The volume ratio in combination with preoperatively available variables can reliably predict postoperative SICU admission following abdominal wall reconstruction. Anticipating such events preoperatively allows for bed space allocation as well as optimizing postoperative care.