Patches in Congenital Diaphragmatic Hernia: Systematic Review.

OBJECTIVE: This systematic review aims to evaluate current choices in practice and outcomes of biomaterials used in patch repair of congenital diaphragmatic hernia (CDH). BACKGROUND: Multiple biomaterials, both novel and combinations of pre-existing materials are employed in patch repair of large size CDHs. METHODS: A literature search was performed across Embase, Medline, Scopus, and Web of Science. Publications that explicitly reported patch repair, material used, and recurrences following CDH repair were selected. RESULTS: Sixty-three papers were included, presenting data on 4595 patients, of which 1803 (39.2%) were managed using 19 types of patches. Goretex® (GTX) (n=1106) was the most frequently employed patch followed by Dualmesh® (n=267), Surgisis® (n=156), Marlex®/GTX® (n=56), Tutoplast dura® (n=40), Dacron® (n=34), Dacron®/GTX® (n=32), Permacol® (n=24), Teflon® (n=24), Surgisis®/GTX® (n=15), Sauvage® Filamentous Fabric (n=13), Marlex® (n=9), Alloderm® (n=8), Silastic® (n=4), Collagen coated Vicryl® mesh (CCVM) (n=1), Mersilene® (n=1), and MatriStem® (n=1) Biomaterials were further subgrouped as: synthetic nonresorbable (SNOR) (n=1458), natural resorbable (NR) (n=241), combined natural and synthetic nonresorbable (NSNOR) (n=103), and combined natural and synthetic resorbable (NSR) (n=1). The overall recurrence rate for patch repair was 16.6% (n=299). For patch types with n>20, recurrence rate was lowest in GTX/Marlex (3.6%), followed by Teflon (4.2%), Dacron (5.6%), Dualmesh (12.4%), GTX (14.8%), Permacol (16.0%), Tutoplast Dura (17.5%), SIS/GTX (26.7%), SIS (34.6%), and Dacron/GTX (37.5%).When analyzed by biomaterial groups, recurrence was highest in NSR (100%), followed by NR (31.5%), NSNOR (17.5%), and SNOR the least (14.0%). CONCLUSION: In this cohort, over one-third of CDH were closed using patches. To date, 19 patch types/variations have been employed for CDH closure. GTX is the most popular, employed in over 60% of patients; however, excluding smaller cohorts (n<20), GTX/Marlex is associated with the lowest recurrence rate (3.6%). SNOR was the material type least associated with recurrence, while NSR experienced recurrence in every instance.

Outcomes of Transversus Abdominis Release With Macroporous Polypropylene Mesh.

INTRODUCTION: Transversus abdominis release (TAR) is increasingly being performed for reconstruction of complex incisional and recurrent ventral hernias, with complication rates ranging from 17.4% to 33.3% after open TAR (oTAR) or robotic TAR (rTAR). The purpose of this study was to describe the outcomes of patients undergoing TAR with macroporous polypropylene mesh (MPM) and to compare outcomes between oTAR and rTAR. METHODS: A retrospective review of 183 consecutive patients undergoing TAR with MPM performed by a single surgeon at a single institution from 2015 to 2021 was performed. Patients with less than one year of follow-up were excluded. Univariate analysis was performed to compare outcomes between oTAR and rTAR patients. RESULTS: Average patient age was 59.4 y, median body mass index was 33.2 kg/m2, and median hernia width was 12.0 cm. Forty 2 (23%) patients underwent oTAR, 127 (69%) underwent rTAR, and 14 (8%) underwent laparoscopic TAR. Patients experienced 16.4%, 10.4%, 3.8%, and 6.0% rates of overall complications, surgical site occurrences, surgical site infections, and other complications, respectively. At average follow-up of 2.3 y, a 2.7% hernia recurrence rate was observed. In comparison to patients undergoing oTAR, rTAR patients required shorter operative times and length of stay, and were less likely to experience postoperative complications overall, and other complications. Recurrence rates were similar between oTAR and rTAR. CONCLUSIONS: Patients undergoing TAR with MPM experienced complication and recurrence rates in alignment with previously published results. In comparison to oTAR, rTAR was associated with more favorable perioperative outcomes and complication rates, but similar recurrence rates.

Robotic-assisted endoscopic onlay repair (R-ENDOR) for concomitant ventral hernias and diastasis recti: initial results and surgical technique.

BACKGROUND: The surgical management of midline ventral hernias complicated by concomitant diastasis recti presents a significant clinical challenge. The Endoscopic Onlay Repair (ENDOR) offers a minimally invasive solution, effectively addressing both conditions. This study focuses on describing the adaptation of ENDOR to a robotic platform, termed R-ENDOR, aiming to report initial outcomes along with other established robotic surgical approaches. METHODS: This retrospective case series study included consecutive adult patients who underwent R-ENDOR approach from October 2018 to April 2023, performed by a single surgeon. A comprehensive description of the surgical technique is included. Patient demographics, operative, and hernia-specific characteristics, as well as clinical outcomes are described. RESULTS: A total of 15 patients undergoing R-ENDOR for ventral hernia repair with diastasis recti plication were included. The median age was 59 years (IQR 42-63), with 60% (n = 9) female patients. The majority (86%, n = 13) had an ASA score of ≤ 2, and the median BMI was 24 kg/m2, with 20% (n = 3) classified as obese. Median hernia size was 2 cm (IQR 2-2.25), with a median diastasis length of 19 cm (IQR 15-21.5) and width of 4 cm (IQR 3-6). The median operative time was 129 min (IQR 113-166). Most repairs (93%, n = 14) were reinforced with mesh, predominantly self-fixating (73.3%, n = 11). Eighty percent of patients (n = 12) were discharged on the same day, with a median follow-up of 153 days (IQR 55-309). Notable complications included clinically significant seromas in 20% of patients (n = 3), long-term hypoesthesia in 40% (n = 6), and readmission in one patient (6.6%) for surgical site infection (SSI) requiring IV antibiotic therapy. CONCLUSION: Midline ventral hernias associated to diastasis recti can be managed robotically by ENDOR with safe and consistent 90-day outcomes in a carefully selected group of patients.

Quality of life following repair of large hiatal hernia is not influenced by the use of mesh-Longer-term follow-up from a randomized trial.

INTRODUCTION: The use of prosthetic mesh in laparoscopic repair of large hiatus hernias remains controversial. Clinical and quality of life outcomes from a randomized controlled trial of mesh versus suture repair previously showed few differences at early follow-up. This study evaluated longer-term quality of life outcomes from that trial. METHODS: A prospective, multicentre, double blind randomized controlled trial assessed three methods of repair for large hiatus hernias: sutures-only versus absorbable mesh versus non-absorbable mesh. Quality of life was assessed using the Short-Form 36 (SF-36) questionnaire which was completed preoperatively and then at 3, 6, 12 months following surgery and annually thereafter. SF-36 outcomes were compared across the three repair techniques at longer-term follow-up (3-6 years), and to earlier baseline and 12-month outcomes. RESULTS: 126 patients were randomized; 43-suture-only, 41-absorbable mesh and 42-non-absorbable mesh. Questionnaires were completed by 118 patients preoperatively, 115 at 12 months and 98 at longer-term follow-up (median 5 years). There were no significant differences between the repair techniques for the subscale and composite scores at longer-term follow-up. The mental component score improved significantly after surgery and was sustained across follow-up for all techniques. The physical component score also improved significantly but was lower at longer-term follow-up compared to the 12-month follow up in both mesh groups. CONCLUSION: Surgical repair of large hiatus hernias provides sustained long-term improvement in quality of life. The addition of mesh does not improve quality of life. TRIAL REGISTRATION: This trial is registered with the Australia and New Zealand Clinical Trials Registry ACTRN12605000725662.

Impact of pre-existing mesh at the hiatus at revisional hiatal hernia surgery.

Recurrence after laparoscopic hiatus hernia repair (LHR) is high, with few symptomatic patients undergoing redo LHR. Morbidity is higher in redo surgery compared with the primary operation. Tens of studies have explored the safety of redoing LHR. However, the impact of existing mesh on operative risk is rarely examined. We aim to assess the impact of mesh at the hiatus on the safety of redo LHR. This was a cohort study examining redo LHR patients from a prospectively maintained database from January 2002 to December 2023. The primary outcome was intra-/postoperative complications. Follow-up was extracted from clinical records. Predictors of complications were assessed using univariable and multivariable logistic regression analyses. Redo LHR was performed in 100 patients; 22 had previous mesh. One encountered mortality with 23 complications. Five patients had absorbable mesh, with the remainder nonabsorbable. Overall complications were significantly higher with mesh at nine (40.9%) compared to no mesh redo at 14 (17.9%), P = 0.023. There was no difference in rates of visceral injury with mesh at four (18.2%) and no mesh at six (7.7%), P = 0.22. The median follow-up was 7 months; there was no difference in reflux rates (P = 0.70) but higher rates of dysphagia (P = 0.010). Higher overall complications were noted in patients with previous hiatal mesh repair at the time of LHR. However, major visceral complications were similar regardless of mesh use. Mesh at the hiatus should not be a deterrent for reoperative hiatus surgery.

Meta-analysis of RCTs on the safety of non-fixation of mesh in TAPP inguinal hernia repair: an updated meta-analysis.

OBJECTIVE: This meta-analysis aims to compare the clinical efficacy of mesh non-fixation and fixation in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, systematically evaluating the application value of the mesh non-fixation technique in clinical settings. METHODS: A computerized search of PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases was conducted to identify randomized controlled trials (RCTs) comparing mesh non-fixation and fixation in TAPP inguinal hernia repair. Meta-analysis was performed using RevMan 5.3 software, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence grading system was employed for outcome quality assessment. Publication bias analysis was performed using Begg's test. A trial sequential analysis (TSA) was performed using TSA 0.9.5.10 Beta software. RESULTS: A total of nine RCTs involving 1,879 inguinal hernia patients were included. Meta-analysis results demonstrated that, compared to the fixation group, the non-fixation group exhibited significantly lower seroma occurrence rate [RR = 0.43, 95% CI (0.20, 0.89), P = 0.02, heterogeneity P = 0.28, I²=22%], Visual Analog Scale (VAS) pain score at 6 months postoperatively [MD=-0.21, 95% CI (-0.29, -0.12), P < 0.00001, heterogeneity P = 0.34, I²=0%], and cost [MD=-3.23 thousand yuan, 95% CI (-4.26, -2.19), P < 0.00001, heterogeneity P = 0.0003, I²=92%]. There were no statistically significant differences in overall complication rate [RR = 0.88, 95% CI (0.62, 1.23), P = 0.45, heterogeneity P = 0.11, I²=44%], overall infection event rate [RR = 0.96, 95% CI (0.36, 2.56), P = 0.93, heterogeneity P = 0.62, I²=0%] and recurrence rate [RR = 0.75, 95% CI (0.28, 1.99), P = 0.56, heterogeneity P = 0.44, I²=0%] between the two groups. The results of the TSA indicated that the observed lower seroma occurrence rate in the non-fixation group compared to the fixation group requires further validation through the inclusion of additional RCTs. CONCLUSION: Mesh non-fixation in TAPP inguinal hernia repair is deemed safe and does not elevate the risk of hernia recurrence. However, given certain limitations in this study, future comprehensive and reliable validation will require further multicenter, high-quality, large-sample double-blind RCTs.

Coatings for Permanent Meshes Used to Enhance Healing in Abdominal Hernia Repair: A Scoping Review.

INTRODUCTION: Hernia meshes are used to reduce recurrence and pain rates, but the rates are still high. This could be improved with coatings of the mesh. This scoping review aimed to provide an overview of mesh coatings used to promote healing in abdominal hernia repair and to report beneficial and unbeneficial effects. METHODS: We included human and animal studies with abdominal hernias that were repaired with non-commercially coated meshes. We searched Pubmed, Embase, Cochrane Central, LILACS, and CNKI without language constraints. RESULTS: Of 2933 identified studies, 58 were included: six studies had a total of 408 humans and 52 studies had 2679 animals. The median follow-up was 12 months (range 1-156), and 95% of the hernias were incisional. There were 44 different coatings which included platelet-rich plasma, mesenchymal stem cells, growth factors, vitamin E, collagen-derived products, various polysaccharides, silk proteins, chitosan, gentamycin, doxycycline, nitrofurantoin, titanium, and diamond-like carbon. Mesenchymal stem cells and platelet-rich plasma were the most researched. Mesenchymal stem cells notably reduced inflammation and foreign body reactions but did not impact other healing metrics. In contrast, platelet-rich plasma positively influenced tissue ingrowth, collagen deposition, and neovascularization and had varying effects on inflammation and foreign body reactions. CONCLUSION: We identified 44 different mesh coatings and they showed varying results. Mesenchymal stem cells and platelet-rich plasma were the most studied, with the latter showing considerable promise in improving biomechanical properties in hernia repair. Further investigations are needed to ascertain their definitive use in humans.

Modified Chevrel Technique: A Lifesaver for Surgeons.

Background and Objectives: Ventral hernias (VH) pose significant challenges for surgeons due to the risk of recurrence, complexities in aligning abdominal muscles, and selecting the most suitable layer for mesh augmentation. This study aims to evaluate the effectiveness of utilizing the anterior rectus fascia as a turnover flap in conjunction with onlay mesh reinforcement, a procedure known as the modified Chevrel technique (MCT). Materials and Methods: We conducted a retrospective analysis of patients who were operated on using MCT for abdominal hernias between January 2013 and December 2019. Data were extracted from our hospital's electronic database. Recurrence rates, as well as the rates of surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrences requiring procedural intervention (SSOPI), were analyzed based on patients' comorbidities and demographic characteristics. Results: The median follow-up period was 42.9 months (range: 14-96), and the recurrence rate was 4% (n = 3). Among the recurrent cases, three patients had chronic obstructive pulmonary disease, representing a statistically significant association (p = 0.02). Although all patients with recurrence were obese, this association did not reach statistical significance (p > 0.05). The mean hospitalization duration was 17.6 days (range: 6-29). SSO, SSI, and SSOPI rates were 39 (52%), 12 (16%), and 32 (42%), respectively. Conclusions: Managing VH remains a surgical challenge, emphasizing the importance of achieving effective abdominal closure for both functional and cosmetic outcomes. MCT presents a relatively simple approach compared to techniques like transversus abdominis release (TAR) and anterior component separation (ACS), with acceptable rates of SSO, SSOPI, SSI, and recurrence.

[The results of clinical application of the mesh with anti-adhesive fluoropolymer coating in laparoscopic intraperitoneal repair of primary ventral hernia]. / Rezul'taty klinicheskogo primeneniya setchatogo endoproteza s antiadgezivnym ftorpolimernym pokrytiem pri laparoskopicheskoi intraperitoneal'noi plastike pervichnykh ventral'nykh gryzh.

OBJECTIVE: The purpose of the study was to evaluate the results of using fluoropolymer-coated mesh during intraperitoneal onlay mesh hernia repair in patients with primary ventral hernias. MATERIAL AND METHODS: The multicenter, non-randomized, controlled clinical study included 88 patients of both sexes who were operated on using a laparoscopic approach using the IPOM technique for a primary ventral hernia. The duration of observation ranged from 3 to 12 months. In the main group, 48 patients received fluoropolymer-coated meshes (Ftorex). A comparison was made with a retrospective group of 40 patients who were treated with anti-adhesive collagen-coated meshes (Parietene composite, Parietex Composite, Symbotex). RESULTS: The number of early and late postoperative complications in the groups did not have significant differences, at the same time, their number was lower in the group of patients in whom fluoropolymer-coated meshes were used. Most of the complications corresponded to Clavien-Dindo class I and II and did not pose a significant threat to health. There were no recurrences of hernias observed in patients included in the study. There were slightly more adhesions in the fluoropolymer-coated mesh group (35.4% vs. 25.0% in the collagen-coated mesh group). The quality of life of patients in the study groups did not differ. CONCLUSION: In laparoscopic IPOM hernia repair fluoropolymer-coated meshes are not inferior in effectiveness and safety to traditionally used collagen-coated meshes and can be recommended for use in patients with primary ventral hernias.

Laparoscopic Paraesophageal Hernia Repair: To Mesh or not to Mesh. Systematic Review and Meta-analysis.

OBJECTIVE: This study aimed to compare outcomes after laparoscopic paraesophageal hernia repair (LPEHR) with mesh or primary repair alone. SUMMARY OF BACKGROUND DATA: High recurrence rates after LPEHR have been reported. Whether the use of mesh improves outcomes remains elusive. METHODS: A systematic literature search was performed to identify randomized controlled trials (RCTs) comparing LPEHR with mesh repair versus suture repair alone. Early (≤6 months) and late (>6 months) recurrence rates were used as primary endpoints to assess efficacy. Intraoperative complications, overall morbidity, and reoperation rates were used as secondary endpoints to assess safety. A meta-analysis was conducted using relative risks (RR) with 95% confidence intervals (CI) for the analyzed outcomes. RESULTS: Seven RCTs comparing mesh (n = 383) versus suture only (n = 352) repair were included for analysis. Patients undergoing LPEHR with mesh reinforcement had similar early (RR = 0.74, 95% CI = 0.26-2.07, P = 0.46) and late (RR = 0.75, 95% CI = 0.27-2.08, P = 0.48) recurrence rates as those with primary repair. Similar recurrence rates were also found when stratifying the analysis by the type of mesh utilized (absorbable and nonabsorbable). Intraoperative complications (RR = 1.03, 95% CI = 0.33-3.28, P = 0.92) and reoperation rates (RR = 0.75, 95% CI = 0.29-1.92, P = 0.45) were also similar in both groups. Overall morbidity, however, was higher after mesh repair with nonabsorbable mesh (RR = 1.45, 95% CI = 1.24-1.71, P < 0.01). CONCLUSIONS: Patients undergoing LPEHR have similar early and late recurrence rates with either mesh reinforcement or suture only repair, regardless of the type of mesh utilized. Overall morbidity, however, seems to be higher in patients repaired with nonabsorbable mesh.

Long-term Comparison of Recurrence Rates Between Different Lightweight and Heavyweight Meshes in Open Anterior Mesh Inguinal Hernia Repair: A Nationwide Population-based Register Study.

OBJECTIVE: To compare the reoperation rate for recurrence of different lightweight to heavyweight meshes after an open anterior mesh (OAM) inguinal hernia repair. SUMMARY BACKGROUND DATA: Lightweight meshes have shown benefits compared with heavyweight meshes in terms of accelerated recovery after surgery with less postoperative pain. The use of such meshes may, however, be associated with an increase in hernia recurrence. Studies of large cohorts with long-term follow-up regarding recurrence are lacking. METHODS: All OAM groin hernia repairs registered in The Swedish Hernia Register between January 1, 2005 and December 31, 2013 were eligible. Follow-up time was until June 30, 2016. Four groups of meshes were included: polypropylene (PP) heavyweight meshes >50 g/m2 (HWM), regular lightweight PP meshes <50 g/m2 (regular LWM-PP), lightweight PP mesh with absorbable poliglecaprone-25(LWM-PP/PGC), or polyglactin-910(LWM-PP/PG). Primary endpoint was reoperation for recurrence. RESULTS: 76,495 OAM inguinal hernia repairs in male patients were included for statistical analysis. 1676 repairs were reoperated for recurrence. Multivariate analysis demonstrated no significant difference of risk for recurrence between HWM and regular LWM-PP (HR 1.12, P = 0.13). LWM-PP/PGC (HR 1.42, P < 0.001) and LWM-PP/PG (HR 2.05, P < 0.001) resulted in a significant increased risk compared with HWM. Larger hernia defects, direct hernias, and recurrent hernias were associated with an increased risk of reoperation for recurrence. CONCLUSIONS: Although lightweight meshes with partially absorbable component resulted in an increased risk of recurrence, there was no difference between regular LWM-PP and HWM. Considering that regular LWM-PP has less associated side effects there are no benefits of using HWM in OAM inguinal hernia repair.

Impact of Trainee Participation on Inguinal Hernia Repair Outcome: A Study Based on the Swedish Hernia Register.

OBJECTIVE: The aim of this study was to investigate whether differences in postoperative outcome exist between open inguinal hernia repairs performed by surgical trainees and those performed by specialist surgeons. SUMMARY OF BACKGROUND DATA: Inguinal hernia repair is the prototype educational surgical procedure. The impact of trainee participation on postoperative outcome is still controversial and despite earlier studies no reliable hernia-specific data exist. METHODS: The study cohort was based on the Swedish Hernia Register and consisted of 61,161 cases of male patients aged 18 years and older with open anterior mesh repair of a primary inguinal hernia between January 1, 2002, and December 31, 2014. The study cohort was selected to represent the typical trainee procedure in Sweden. Primary outcome measures were reoperation due to hernia recurrence and postoperative 30-day complications. RESULTS: Procedures with longer operating times were at a higher risk for reoperation when performed by supervised trainees [57 to 72 minutes: hazard ratio (HR) 1.55, 99% confidence interval (99% CI) 1.05-2.27] or unsupervised trainees (57 to 72 minutes: HR 1.60, 99% CI 1.18-2.17; >72 minutes: HR 1.72, 99% CI 1.25-2.37). The same was true for specialist and trainee-assisted specialists with operating times <43 minutes (HR 1.63, 99% CI 1.25-2.13; HR 1.58, 99% CI 1.09-2.28). Postoperative 30-day complications were generally associated with longer operating times and occurred at all levels of experience. CONCLUSION: Trainee participation in open inguinal repair in combination with longer operating time is a risk factor associated with higher reoperation rates. This calls for a more structured supervision of trainees in an assumedly basic procedure.

Glue versus mechanical mesh fixation in laparoscopic inguinal hernia repair: meta-analysis and trial sequential analysis of randomized clinical trials.

BACKGROUND: The optimal choice for mesh fixation in laparoscopic inguinal hernia repair (LIHR) has not been well established. This review compared the effects of glue versus mechanical mesh fixation in LIHR on incidence of chronic postoperative inguinal pain (CPIP) and other secondary outcomes, including acute pain, seroma, haematoma, hernia recurrence and other postoperative complications. METHODS: A systematic review of English/non-English studies using MEDLINE, the Cochrane Library, OpenGrey, OpenThesis and Web of Science, and searching bibliographies of included studies was completed. Search terms included laparoscopic, hernia, fibrin glue, Tisseel, Tissucol, cyanoacrylate, Glubran and Liquiband. Only RCTs comparing mechanical with glue-based fixation in adult patients (aged over 18 years) that examined CPIP were included. Two authors independently completed risk-of-bias assessment and data extraction against predefined data fields. All pooled analyses were computed using a random-effects model. RESULTS: Fifteen RCTs met the inclusion criteria; 2777 hernias among 2109 patients were assessed. The incidence of CPIP was reduced with use of glue-based fixation (risk ratio (RR) 0.36, 95 per cent c.i. 0.19 to 0.69; P = 0.002), with moderate heterogeneity that disappeared with sensitivity analysis (8 d.f.) for patient-blinded studies (RR 0.43, 0.27 to 0.86). Trial sequential analysis provided evidence for a relative risk reduction of at least 25 per cent. The incidence of haeamtoma was reduced by using glue-based fixation (RR 0.29, 0.10 to 0.82; P = 0.02) with no significant effects on seroma formation or hernia recurrence (RR 1.07, 0.46 to 2.47; P = 0.88). CONCLUSION: Glue-based mesh fixation appears to reduce the incidence of CPIP and haematoma after LIHR compared with mechanical fixation, with comparable recurrence rates.

Chronic pain after open inguinal hernia repair: expertise-based randomized clinical trial of heavyweight or lightweight mesh.

BACKGROUND: There is a shortage of high-quality studies regarding choice of mesh in open anterior inguinal hernia repair in relation to long-term chronic pain. The authors hypothesized that heavyweight compared with lightweight mesh causes increased postoperative pain. METHODS: An RCT was undertaken between 2007 and 2009 at two sites in Sweden. Men aged 25 years or older with an inguinal hernia evaluated in the outpatient clinic were randomized in an unblinded fashion to heavyweight or lightweight mesh for open anterior inguinal hernia repair. Data on pain affecting daily activities, as measured by the Short-Form Inguinal Pain Questionnaire 9-12 years after surgery, were collected as the primary outcome. Differences between groups were evaluated by generalized odds and numbers needed to treat. RESULTS: A total of 412 patients were randomized; 363 were analysed with 320 questionnaires sent out. A total of 271 questionnaires (84.7 per cent) were returned; of these, 121 and 150 patients were in the heavyweight and lightweight mesh groups respectively. Pain affecting daily activities was more pronounced in patients randomized to heavyweight versus lightweight mesh (generalized odds 1.33, 95 per cent c.i. 1.10 to 1.61). This translated into a number needed to treat of 7.06 (95 per cent c.i. 4.28 to 21.44). Two reoperations for recurrence were noted in the heavyweight mesh group, and one in the lightweight mesh group. CONCLUSION: A large-pore lightweight mesh causes significantly less pain affecting daily activities a decade after open anterior inguinal hernia repair. Registration number: NCT00451893 (http://www.clinicaltrials.gov).

Early Clinical and Patient-Reported Outcomes of a New Hybrid Mesh for Incisional Hernia Repair.

INTRODUCTION: Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, SynecorTM, for Ventral Hernia Repair (VHR). METHODS: Adult (>18 y old) patients undergoing VHR with SynecorTM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL. RESULTS: Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m2, respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05). CONCLUSIONS: Abdominal reinforcement with SynecorTM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.

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.

Dual Tack Mesh Fixation System on a Cadaveric Porcine Model-Creation of a Mesh Fixation System for Hernia Treatment and Prevention.

BACKGROUND: Onlay mesh repair (OMR) has proven to be a widely used, simple, and effective technique for treatment and prevention of hernia occurrence. Despite established benefits, there is still a lack of widespread adoption. In this study, we present the Dual Tacker Device (DTD), an enabling technology that directly addresses the limitations to the adoption of OMR, saving surgical time and effort and making OMR more reproducible across a wide range of patients. METHODS: The DTD mesh fixation system is a semiautomated, hand-held, disposable, multipoint onlay mechanical mesh fixation system that is able to rapidly and uniformly tension and fixate mesh for both hernia treatment and prevention. A cadaveric porcine model was used as a pilot test conducted during a 2 day session to assess the usability of the device and to show that the DTD provided equivalent or superior biomechanical support compared with the standard of care (hand-sewn, OptiFix). RESULTS: Our study included 37 cadaveric porcine incisional closure abdominal wall models. These were divided into four groups: DTD-mediated OMR (n = 14), hand-sewn OMR (n = 7), OptiFix OMR (n = 9), and suture-only repair (no mesh) (n = 7). Eight surgical residents performed device-mediated and hand-sewn OMR. Average time to completion was fastest in the DTD cohort (45.6s) with a statistically significant difference compared with the hand-sewn cohort (343.1s, P < 0.01). No difference in tensile strength was noted between DTD (195.32N), hand-sewn (200.48N), and OptiFix (163.23N). Discreet hand movements were smallest in the DTD (29N) and significant (P < 0.01) when compared with hand-sewn (202N) and OptiFix (35N). CONCLUSIONS: The use of the DTD is not only feasible, but demonstrated improvement in time to completion and economy of movement over current standard of care. While more testing is needed and planned, compared with conventional approaches, the DTD represents a robust proof of principle with promising implications for clinical feasibility and adoptability.

Appropriate mesh size in the totally extraperitoneal repair of groin hernias based on the intraoperative measurement of the myopectineal orifice.

BACKGROUND: Insufficient coverage of the area of a possible groin hernia is an important risk factor in hernia recurrence. To prevent recurrence, it is important to use the appropriate mesh size based on the size of the myopectineal orifice (MPO), which is the weak area of the abdominal wall where inguinal hernias occur. We aimed to estimate the appropriate mesh size for groin hernias by investigating MPO size. METHODS: Four hundred and six patients underwent groin hernia repair using a totally extraperitoneal (TEP) approach at the Zeze Hospital between July 2009 and December 2017. We investigated patients' backgrounds, MPO components dimensions, and hernia recurrence, and evaluated the appropriate mesh size. RESULTS: The 359 male and 47 female patients had an average age of 63 ± 15 years. In 171, 147, and 88 cases, hernias were localized to the right, left, and bilaterally, respectively. The number of lateral, medial, femoral, and combined hernias was 317, 124, 11, and 42, respectively. The 95th percentile for the horizontal and vertical lengths in cases of hernia orifice ≥ 3 cm were 9.6 cm and 7.0 cm, respectively, while it was 9.2 cm and 6.4 cm in cases of hernia orifice < 3 cm. We added 2 cm and 3 cm to the 95th percentile for the length and width of the MPO, resulting in 13.2 × 10.4 cm and 15.6 × 13.0 cm in cases with hernia orifice < 3 cm and ≥ 3 cm, respectively. Relapse after TEP occurred in 1 patient (0.2%). CONCLUSION: The appropriate mesh size for TEP repair, derived from intraoperative MPO measurements, was estimated as 13.2 × 10.4 cm and 15.6 × 13.0 cm when the hernia orifice was < 3 cm and ≥ 3 cm, respectively. Using appropriate mesh sizes based on MPO measurement may reduce groin hernia recurrence after TEP.

Laparoscopic parastomal hernia repair delays recurrence relative to open repair.

BACKGROUND: Mesh repair of parastomal hernia is widely accepted as superior to non-mesh repair, yet the most favorable surgical approach is a subject of continued debate. The aim of this study was to compare the clinical outcomes of open versus laparoscopic parastomal hernia repair. METHODS: An IRB-approved retrospective review was conducted comparing laparoscopic (LPHR) or open (OPHR) parastomal hernia repair performed between 2009 and 2017 at our facilities. Patient demographics, preoperative characteristics, operative details, and clinical outcomes were compared by surgical approach. Subgroup analysis was performed by location of mesh placement. Repair longevity was measured using Kaplan-Meier method and Cox proportional hazards regression. Intention to treat analysis was used for this study based on initial approach to the repair. RESULTS: Sixty-two patients (average age of 61 years) underwent repair (31 LPHR, 31 OPHR). Patient age, gender, BMI, ASA Class, and comorbidity status were similar between OPHR and LPHR. Stoma relocation was more common in OPHR (32% vs 7%, p = .022). Open sublay subgroup was similar to LPHR in terms of wound class and relocation. Open "Other" and Sublay subgroups resulted in more wound complications compared to LPHR (70% and 48% vs 27%, p = .036). Operative duration and hospital length of stay were less with LPHR (p < .001). After adjustment for prior hernia repair, risk of recurrence was higher for OPHR (p = .022) and Open Sublay and Other subgroups compared to LPHR (p = .005 and p = .027, respectively). CONCLUSIONS: Laparoscopic repair of parastomal hernias is associated with shorter operative duration, decreased length of stay, fewer short-term wound complications, and increased longevity of repair compared to open repairs. Direct comparison of repair longevity between LPHR and OPHR with mesh using Kaplan-Meier estimate is unique to this study. Further study is warranted to better understand methods of parastomal hernia repair associated with fewer complications and increased durability.

The current state of robotic retromuscular repairs-a qualitative review of the literature.

BACKGROUND: The management of ventral incisional hernias (VIH) has undergone many iterations over the last 5 years due to evolution in surgical techniques and advancement in robotic surgery. Four general principles have emerged: mesh usage, retromuscular mesh placement, primary fascial closure, and usage of minimally invasive techniques when possible. The application of robotic retromuscular repairs in VIH allow these principles to be applied simultaneously. This qualitative review attempts to answer what robotic retromuscular repairs are described, which patients are selected for these techniques, and what are current outcomes. METHODS: Using the key words: "robotic retromuscular repair", "robotic Rives Stoppa", and "robotic transversus abdominis release", a PubMed search of articles written up to December 2019 was critically reviewed. RESULTS: 44 articles were encountered, 9 high-quality articles were analyzed for this manuscript. Level of evidence ranged from 2B to 2C. Robotic TAR patients had BMI of 33 kg/m2, defect sizes ranging from 7-14 cm wide to 12-19 cm long, longer OR times, no difference in surgical site events, and shorter length of stay (LOS). The techniques to perform robotic Rives Stoppa (RS) were heterogeneous; however, extended totally extraperitoneal (ETEP) approach is most described. Defect width for RS repairs ranged 4-7 cm and LOS was less than 1 day. Complication rates were low, there is no long-term data on hernia recurrence, and information on cost is limited. CONCLUSION: In short-term follow-up, robotic retromuscular repairs show promise that VIH can be repaired with intramuscular mesh, few complications, and shorter LOS. Data on hernia recurrence, long-term complications, and rigorous cost analysis are needed to demonstrate generalizability.