Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia.

INTRODUCTION: Prophylactic meshes in high-risk patients prevent incisional hernias, although there are still some concerns about the best layer to place them in, the type of fixation, the mesh material, the significance of the level of contamination, and surgical complications. We aimed to provide answers to these questions and information about how the implanted material behaves based on its visibility under magnetic resonance imaging (MRI). METHOD: This is a prospective multicentre observational cohort study. Preliminary results from the first 3 months are presented. We included general surgical patients who had at least two risk factors for developing an incisional hernia. Multivariate logistic regression was used. A polyvinylidene fluoride (PVDF) mesh loaded with iron particles was used in an onlay position. MRIs were performed 6 weeks after treatment. RESULTS: Between July 2016 and June 2022, 185 patients were enrolled in the study. Surgery was emergent in 30.3% of cases, contaminated in 10.7% and dirty in 11.8%. A total of 5.6% of cases had postoperative wound infections, with the requirement of stoma being the only significant risk factor (OR = 7.59, p = 0.03). The formation of a seroma at 6 weeks detected by MRI, was associated with body mass index (OR = 1.13, p = 0.02). CONCLUSIONS: The prophylactic use of onlay PVDF mesh in midline laparotomies in high-risk patients was safe and effective in the short term, regardless of the type of surgery or the level of contamination. MRI allowed us to detect asymptomatic seromas during the early process of integration. STUDY REGISTRATION:  This protocol was registered at ClinicalTrials.gov (NCT03105895).

Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss.

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p < .001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, p < .001), graft loss (HR 0.371, 95% CI 0.267-0.516, p < .001), and patient death (HR 0.540, 95% CI 0.373-0.781, p = .001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, p = .021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, p < .001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.

Reverse TAR may be added when necessary in open preperitoneal repair of lateral incisional hernias: a retrospective multicentric cohort study.

BACKGROUND: The best approach for lateral incisional hernia is not known. Posterior component separation (reverse TAR) offers the possibility of using the retromuscular space for medial extension of the challenging preperitoneal plane. The aim of our multicenter study was to compare the operative and patient-reported outcomes measures (PROMs) using two open surgical techniques from the lateral approach: a totally preperitoneal vs a reverse TAR. METHODS: A retrospective cohort study was performed since 2012 to 2020. Patients with lateral incisional hernia treated through a lateral approach were identified from a prospectively maintained multicenter database. Reverse TAR was added when the preperitoneal plane could not be safely dissected. The results obtained using these two lateral approaches were compared, including short- and long-term complications, as well as PROMs, using the specific tool EuraHSQoL. RESULTS: A total of 61 patients were identified. Reverse TAR was performed in 33 patients and lateral retromuscular preperitoneal approach in 28 patients. Both groups were comparable in terms of sociodemographic and comorbidities variables. Surgical site occurrences occurred in 13 cases (21.3%), with 8 patients (13.1%) requiring procedural intervention. During a median follow-up of 34 months, no incisional hernia recurrence was registered. There was a case (1.6%) of symptomatic bulging that required reoperation. Also 12 patients (19.7%) presented an asymptomatic bulging. No statistically significant difference was identified in the complications and PROMs between the two procedures. CONCLUSION: The open lateral retromuscular reconstruction using very large meshes that reach the midline has excellent long-term results with acceptable postoperative complications, including PROMs. A reverse TAR may be added, when necessary, without increasing complications and obtaining similar long-term results.

Incidence and risk factors of delayed development for stoma site incisional hernia after ileostomy closure in patients undergoing colorectal surgery with temporary ileostomy.

BACKGROUND: Stoma site incisional hernias after ileostomy closure are complex hernias that can be associated with abdominal pain, discomfort, and a diminished quality of life. The aim of this study was to determine the incidence of incisional hernia (IH) following temporary ileostomy reversal in patients undergoing colorectal surgery, and the risk factors associated with its development. METHODS: This was a prospective, single-centre, cohort study of patients undergoing ileostomy reversal between January 2010 and December 2016. Comorbidities, operative characteristics, comparison between early and late ileostomy closure and postoperative complications were analysed. RESULTS: A total of 202 consecutive patients were prospectively evaluated (median follow-up 46 months; range: 12-109). Stoma site incisional hernia occurred in 23% of patients (n = 47), diagnosed by physical examination or imaging tests. The reasons for the primary surgery were colorectal cancer (n = 141, 69.8%), inflammatory bowel disease (n = 14, 6.9%), emergency surgery (n = 35, 17.3%), and other conditions (n = 12, 5.9%). Secondary outcomes: a statistically significant risk factors for developing an IH was obesity (higher BMI) (OR 1.15, 95% CI: 1.05-1.26) p = .003). CONCLUSIONS: 23% of patients developed surgical site IH, a higher BMI being the only risk factor found to be statistically significant in the development of an incisional hernia.

High recurrence rate after posterior component separation and keyhole mesh reconstruction for complex parastomal hernia: A case series study.

AIM: This study aimed to describe the results of complex parastomal hernia repair after posterior component separation and keyhole reconstruction. METHOD: We conducted a retrospective review of a prospectively sustained database in one single complex abdominal wall referral centre. We analysed the data of patients who underwent the posterior component separation technique using modified transversus abdominis release for complex parastomal hernia and retromuscular keyhole mesh repair from February 2014 to January 2017. Demographic data, hernia characteristics, operative details and outcomes were analysed. The primary outcome measured was the recurrence rate during the follow-up. RESULTS: Twenty patients were included in this study. Among the patients who underwent surgery for parastomal hernia, 17 patients had a colostomy (85%) and three patients had a ureteroileostomy after the Bricker procedure (15%). The mean body mass index was 33.2 kg/m2 (range 25-47). Twelve patients had an expected associated risk according to the Carolinas equation for determining associated risk classification of >60%. Sixty per cent of our patients had contaminated or dirty/infected wounds. The overall complication rate was 60%. Surgical site infection was observed in 25% of the cases. The mortality rate in our study group was 5% (n = 1). We found clinical or radiological evidence of parastomal hernia recurrence in nine out of 20 (45%) patients during follow-up. No hernia recurrence was detected in the concomitant incisional hernias. CONCLUSIONS: Although posterior component separation in the form of modified transversus abdominis muscle release allows abdominal wall reconstruction, keyhole mesh configuration at the stoma site does not offer satisfactory results in terms of long-term recurrence rate at the parastomal defect.

Normothermic regional perfusion vs. super-rapid recovery in controlled donation after circulatory death liver transplantation.

BACKGROUND & AIMS: Although there is increasing interest in its use, definitive evidence demonstrating a benefit for postmortem normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation is lacking. The aim of this study was to compare results of cDCD liver transplants performed with postmortem NRP vs. super-rapid recovery (SRR), the current standard for cDCD. METHODS: This was an observational cohort study including all cDCD liver transplants performed in Spain between June 2012 and December 2016, with follow-up ending in December 2017. Each donor hospital determined whether organ recovery was performed using NRP or SRR. The propensity scores technique based on the inverse probability of treatment weighting (IPTW) was used to balance covariates across study groups; logistic and Cox regression models were used for binary and time-to-event outcomes. RESULTS: During the study period, there were 95 cDCD liver transplants performed with postmortem NRP and 117 with SRR. The median donor age was 56 years (interquartile range 45-65 years). After IPTW analysis, baseline covariates were balanced, with all absolute standardised differences <0.15. IPTW-adjusted risks were significantly improved among NRP livers for overall biliary complications (odds ratio 0.14; 95% CI 0.06-0.35, p <0.001), ischaemic type biliary lesions (odds ratio 0.11; 95% CI 0.02-0.57; p = 0.008), and graft loss (hazard ratio 0.39; 95% CI 0.20-0.78; p = 0.008). CONCLUSIONS: The use of postmortem NRP in cDCD liver transplantation appears to reduce postoperative biliary complications, ischaemic type biliary lesions and graft loss, and allows for the transplantation of livers even from cDCD donors of advanced age. LAY SUMMARY: This is a propensity-matched nationwide observational cohort study performed using livers recovered from donors undergoing cardiac arrest provoked by the intentional withdrawal of life support (controlled donation after circulatory death, cDCD). Approximately half of the livers were recovered after a period of postmortem in situ normothermic regional perfusion, which restored warm oxygenated blood to the abdominal organs, whereas the remainder were recovered after rapid preservation with a cold solution. The study results suggest that the use of postmortem normothermic regional perfusion helps reduce rates of post-transplant biliary complications and graft loss and allows for the successful transplantation of livers from older cDCD donors.

Abdominal Wall Reconstruction Utilizing the Combination of Absorbable and Permanent Mesh in a Retromuscular Position: A Multicenter Prospective Study.

BACKGROUND: Optimal mesh reinforcement for abdominal wall reconstruction (AWR) in complex hernias remains questionable. Use of biologic, absorbable and synthetic meshes has been described. The idea of using an absorbable mesh (AM) under a permanent mesh (PM) in a retromuscular position may help in these challenging situations. METHODS: Between 2011 and 2016, consecutive patients undergoing open AWR utilizing an AM as posterior layer reinforcement and configuration of a large PM were identified in a multicenter prospectively maintained database in four hospitals. Main outcomes included demographics, ventral hernia classifications, perioperative data, complications and recurrences. RESULTS: A total of 169 complex incisional hernias were analyzed. Mean age was 60.9, with mean body mass index 30.7 (range: 20-46). Location of incisional hernias (IH) was: 80 midline, 59 lateral and 30 midline and lateral. 78% were grade I and II in Ventral Hernia Working Group classification. 52% of patients were discharged with no complication. There were 19% seromas, 13% hematomas, 12% surgical-site infection and 10% skin dehiscence. Only partial mesh removal was necessary in one patient. After a mean follow-up of 26 months (range 15-59), there were five (3.2%) recurrences. Reoperations on patients showed a band of fibrosis separating the peritoneum from the PM. CONCLUSION: The combination of AM with very large PM in the same retromuscular position in AWR seems to be safe. The efficacy with recurrence rates below 4% in complex midline and lateral IH may be explained by the use of larger PMs that are extended and configured with the support of AMs. Reoperations on patients have confirmed the previous experimental reports on the use of the AM.

How we do it: down to up posterior components separation.

BACKGROUND: Posterior component separation with transversus abdominis release technique is increasingly being used for abdominal wall reconstruction in complex abdominal wall repair. The main purpose of this study is to present a modification of the surgical technique originally described that facilitates the surgical procedure and offers additional advantages. METHODS: Based on the knowledge of the anatomy of the retromuscular space and the preperitoneal aerolar tissue distribution, we start the incision on the posterior rectus sheath from the arcuate line in a down to up direction. The posterior rectus sheath is incised 0,5-1 cm medial to the linea semilunaris and cut longitudinally as far as the fibers of transversus abdominis muscle that are divided in the superior part of the abdomen. It is also possible to avoid cutting the fibers of this muscle if we incise the posterior rectus sheath in an oblique direction to the midline from the umbilical area. Since 2012 to 2016, 69 consecutive patients with down to up TAR have been prospectively followed. Main outcome measures included demographics, perioperative details, wound complications, and recurrences. RESULTS: Between 2012 and 2016, we have operated 69 patients with down to up TAR technique. Mean operative time was 251 (range 65-566) minutes. Mean hospital stay was 9,8 (2-98) days. 10 patients presented surgical site events (14,5%): 6 patients had superficial site infection, 3 deep and 1 organ space. During follow-up, 3 patients (4,3%) presented incisional hernia recurrence. CONCLUSIONS: This novel modification allows a simpler dissection of the preperitoneal retromuscular space and makes the TAR technique easier to perform. It also enables to incise only the insertion of the transversalis fascia cranially.

Acute appendicitis after a colonic endoscopic submucosal resection.

We present a case of acute appendicitis as a complication after an Endoscopic Submucosal Resection of a colonic polyp.

Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014.

INTRODUCTION: endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications. OBJECTIVE: to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment. METHODS AND RESULTS: this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery. CONCLUSIONS: periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management.

Jejunal pseudodiverticulosis. Three cases report.

Jejunal pseudodiverticulosis is an uncommon entity. Pseudodiverticulum are usually asymptomatic and an incidental finding. They can have a less frequent acute onset with perforation, obstruction or bleeding and they could have high morbidity and mortality. We report three patients who debuted with an acute abdomen.

Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery.

OBJECTIVE: To reduce the incidence of incisional hernia (IH) in colorectal surgery by implanting a mesh on the overlay position. BACKGROUND: The incidence of IH in colorectal surgery may be as high as 40%. IH causes severe health and cosmetic problems, and its repair increases health care costs. MATERIAL AND METHODS: Randomized, controlled, prospective trial. Patients undergoing any colorectal procedure (both elective and emergency) through a midline laparotomy were divided into 2 groups. The abdomen was closed with an identical technique in both groups, except for the implantation of an overlay large-pore polypropylene mesh in the study group. Patients were followed up clinically and radiologically for 24 months. RESULTS: A total of 107 patients were included: 53 in the study group and 54 in the control group. Both groups were homogeneous, except for a higher incidence of diabetes in the mesh group. There were 20 emergency procedures in the study group and 17 in the control group. There were no statistical differences in surgical site infections, seromas, or mortality between the groups (33.3%, 13.8%, and 3.7% in the control group and 18.9%, 13.2%, and 3.8% in the study group). No mesh rejection was reported. The incidence of IH was 17 of 54 (31.5%) in the control group and 6 of 53 (11.3%) in the study group (P = 0.011). CONCLUSIONS: The incidence of IH is high in patients undergoing elective or emergency surgery for colorectal diseases. The addition of a prophylactic large-pore polypropylene mesh on the overlay position decreases the incidence of IH without adding morbidity.

[«Surgical¼ analysis of the new clinical practice guide on compartmental syndrome]. / Análisis «quirúrgico¼ sobre la nueva guía de práctica clínica del síndrome compartimental.

The new published guidelines of compartment syndrome are supposed to be a helpful tool in order to make decisions in patients with abdominal hypertension. From a surgical perspective of view, an important effort has been made in order to reach consensus in different phases in which there is no clear answer in evidence-based medicine. It is mandatory the use of a universal classification of open abdomen and there are three main concepts that must be observed: make a decompressive laparotomy when conservative measures have failed, attempt to closure the abdomen as soon as possible and the use of negative-pressure treatments that facilitates the management of an open abdomen. Although most of recommendations that have been delivered are not high grades, the present guide is an important assistant for the management of intra-abdominal hypertension and several lines of investigation are opened in order to answer the doubts that have been addressed.

The Madrid Posterior Component Separation: An Anatomical Approach for Effective Reconstruction of Complex Midline Hernias.

Introduction: In recent years, Posterior Component Separation (PCS) with the Madrid modification (Madrid PCS) has emerged as a surgical technique. This modification is believed to enhance the dissection of anatomical structures, offering several advantages. The study aims to present a detailed description of this surgical technique and to analyse the outcomes in a large cohort of patients. Materials and Methods: This study included all patients who underwent the repair of midline incisional hernias, with or without other abdominal wall defects. Data from patients at three different centres specialising in abdominal wall reconstruction was analysed. All patients underwent the Madrid PCS, and several variables, such as demographics, perioperative details, postoperative complications, and recurrences, were assessed. Results: Between January 2015 and June 2023, a total of 223 patients underwent the Madrid PCS. The mean age was 63.4 years, with a mean BMI of 33.3 kg/m2 (range 23-40). According to the EHS classification, 139 patients had a midline incisional hernia, and 84 had a midline incisional hernia with a concomitant lateral incisional hernia. According to the Ventral Hernia Working Group (VHWG) classification, 177 (79.4%) patients had grade 2 and 3 hernias. In total, 201 patients (90.1%) were ASA II and III. The Carolinas Equation for Determining Associated Risks (CeDAR) was calculated preoperatively, resulting in 150 (67.3%) patients with a score between 30% and 60%. A total of 105 patients (48.4%) had previously undergone abdominal wall repair surgery. There were 93 (41.7%) surgical site occurrences (SSO), 36 (16.1%) surgical site infections (SSI), including 23 (10.3%) superficial and 7 (3.1%) deep infections, and 6 (2.7%) organ/space infections. Four (1.9%) recurrences were assessed by CT scan with an average follow-up of 23.9 months (range 6-74). Conclusion: The Madrid PCS appears to be safe and effective, yielding excellent long-term results despite the complexity of abdominal wall defects. A profound understanding of the anatomy is crucial for optimal outcomes. The Madrid modification contributes to facilitating a complete retromuscular preperitoneal repair without incision of the transversus abdominis. The extensive abdominal wall retromuscular dissection obtained enables the placement of very large meshes with minimal fixation.

[Incisional hernia: open abdominal wall reconstruction. Current state of the technique and results]. / Narbenhernien: offene Operationsverfahren und Ergebnisse einer Kohortenstudie mit 343 Patienten.

The treatment of complex midline hernias remains a particular challenge. The currently refined knowledge of the anatomy in the cadaver laboratory and advancing clinical experience have changed our present approach. The aim of this review is to present a description of the updated surgical procedures and outcomes. We favor the retromuscular or preperitoneal layer for mesh implantation, including the Rives-Stoppa procedure (sublay mesh) and posterior component separation with the Madrid modification. We operated on 334 complex midline incisional hernias: 6.3% retromuscular preperitoneal, 15% after Rives-Stoppa, 2.4% anterior component separation and 76% posterior component separation. A bridging procedure was used in 31%. A complication occurred in 35.3%, most of which were wound healing disorders (SSO). The average length of hospital stay was 7.2 days. We recorded a very low incidence of long-term complications: 3.3% recurrence, 0.9% chronic pain (daily use of pain medication), 6% bulging, 1.8% chronic seroma and 2.6% chronic mesh infection. Despite the associated morbidity, retromuscular/preperitoneal treatment offers excellent long-term results.

Recurrence after retromuscular repair or posterior components separation: How to address them. A retrospective multicentre cohort study.

Abdominal wall hernias are common entities that represent important issues. Retromuscular repair and component separation for complex abdominal wall defects are considered useful treatments according to both short and long-term outcomes. However, failure of surgical techniques may occur. The aim of this study is to analyze results of surgical treatment for hernia recurrence after prior retromuscular or posterior components separation. We have retrospectively reviewed patient charts from a prospectively maintained database. This study was conducted in three different hospitals of the Madrid region with surgical units dedicated to abdominal wall reconstruction. We have included in the database 520 patients between December 2014 and December 2021. Fifty-one patients complied with the criteria to be included in this study. We should consider offering surgical treatment for hernia recurrence after retromuscular repair or posterior components separation. However, the results might be associated to increased peri-operative complications.

Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain.

Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.

Incisions in Hepatobiliopancreatic Surgery: Surgical Anatomy and its Influence to Open and Close the Abdomen.

Incisions performed for hepato-pancreatic-biliary (HPB) surgery are diverse, and can be a challenge both to perform correctly as well as to be properly closed. The anatomy of the region overlaps muscular layers and has a rich vascular and nervous supply. These structures are fundamental for the correct functionality of the abdominal wall. When performing certain types of incisions, damage to the muscular or neurovascular component of the abdominal wall, as well as an inadequate closure technique may influence in the development of long-term complications as incisional hernias (IH) or bulging. Considering that both may impair quality of life and that are complex to repair, prevention becomes essential during these procedures. With the currently available evidence, there is no clear recommendation on which is the better incision or what is the best method of closure. Despite the lack of sufficient data, the following review aims to correlate the anatomical knowledge learned from posterior component separation with the incisions performed in hepato-pancreatic-biliary (HPB) surgery and their consequences on incisional hernia formation. Overall, there is data that suggests some key points to perform these incisions: avoid vertical components and very lateral extensions, subcostal should be incised at least 2 cm from costal margin, multilayered suturing using small bites technique and consider the use of a prophylactic mesh in high-risk patients. Nevertheless, the lack of evidence prevents from the possibility of making any strong recommendations.