Evaluation of long-term performance of an intraperitoneal biomaterial in the treatment of ventral hernias.

BACKGROUND: One-year device safety and clinical outcomes of ventral hernia repair with the GORE® SYNECOR Intraperitoneal Biomaterial, a hybrid composite mesh was evaluated. METHODS: This retrospective, multicenter, case review analyzed device/procedure endpoints and patient-reported outcomes in patients treated for hernia repair ≥ 1 year from study enrollment. RESULTS: Included were 459 patients (with 469 ventral hernias) with a mean age of 58 ± 15 years; 77.1% met Ventral Hernia Working Group 2 (VHWG2) classification. Mean hernia size was 18.9 cm2 and 57.3% of hernias were incisional. Laparoscopic or robotic approach was utilized in 95.4% of patients. Mesh location was intraperitoneal for 75.6% and bridging repair was performed in 57.3%. Procedure-related adverse events within 30-days occurred in 5.0% of patients and included surgical site infection (SSI), surgical site occurrence (SSO), ileus, readmission, and re-operation. Procedure-related SSI or SSO events were 3.8% through 12 months. SSO events requiring procedural intervention (SSOPI) were 2.6% through 24 months. Four patients (0.9%) had confirmed hernia recurrence through the study (the mean follow-up was 32-months, range 14-53 months). Subgroup comparisons were conducted for all type recurrence; only diabetes was found to be statistically significant (p = .0506). CONCLUSION: In this analysis, ventral hernia repair with hybrid, composite mesh results in successful outcomes in most patients. This study represents a heterogeneous patient population undergoing repair using various approaches, mesh fixation, and mesh placement locations. These data appear to confirm long-term acceptable safety and device performance with a low rate of recurrence in a predominantly VHWG2 population.

No difference in outcomes between large- and small-pore meshes in a prospective, randomized, multicenter trial investigating open retromuscular meshplasty for incisional hernia repair.

STUDY DESIGN: A randomized, controlled, prospective multicenter clinical trial with a parallel group design was initiated in eight surgical centers to compare a large-pore polypropylene mesh (Ultrapro®) to a small-pore polypropylene mesh (Premilene®) within a standardized retromuscular meshplasty for incisional hernia repair. METHODS: Between 2004 and 2006, patients with a fascial defect with a minimum diameter of 4 cm after vertical midline laparotomy were recruited for the trial. Patients underwent retromuscular meshplasty with either a large-pore or a small-pore mesh to identify the superiority of the large-pore mesh. Follow-up visits were scheduled at 5 and 21 days and 4, 12, and 24 months after surgery. A clinical examination, a modified short form 36 (SF-36®), a daily activity questionnaire, and an ultrasound investigation of the abdominal wall were completed at every follow-up visit. The primary outcome criterion was foreign body sensation at the 12-month visit, and the secondary endpoint criteria were the occurrence of hematoma, seroma, and chronic pain within 24 months postoperatively. RESULTS: In 8 centers, 181 patients were included in the study. Neither foreign body sensation within the first year after surgery (27.5% Ultrapro®, 32.2% Premilene®) nor the time until the first occurrence of foreign body sensation within the first year was significantly different between the groups. Regarding the secondary endpoints, no significant differences could be observed. At the 2-year follow-up, recurrences occurred in 5 Ultrapro® patients (5.5%) and 4 Premilene® patients (4.4%). CONCLUSION: Despite considerable differences in theoretical and experimental works, we have not been able to identify differences in surgical or patient-reported outcomes between the use of large- and small-pore meshes for retromuscular incisional hernia repair. TRIAL REGISTRATION: Clinical Trials NCT04961346 (16.06.2021) retrospectively registered.

Early Outcome after Sublay versus Onlay Polypropylene Mesh Repair for Ventral Midline Incisional Hernia - A Single Center Retrospective Analysis.

CONTEXT: Onlay and retromuscular sublay mesh repairs are the most frequently used procedures in open repair of midline incisional hernias. The onlay placement of the mesh is simple and fast to perform, while the sublay retromuscular repair offers a supplementary protection against infection, but it is considered a more complicated procedure with a higher risk of early postoperative complications. The personal experience of the surgeons plays an important role in choosing the technique of mesh placement. MATERIAL AND METHODS: This paper presents the results of a retrospective analysis of 220 consecutive patients operated on in the Surgical Clinic of the Mures Clinical County Hospital (Romania) between 31.01.2017 - 31.12.2019 with sublay or onlay polypropylene mesh repair for ventral midline incisional hernia. The patients were divided into two groups according to the position of the mesh. The two groups were identical in terms of age, sex distribution, incidence of comorbidities (obesity, diabetes mellitus, cardiac and respiratory diseases), number of previous operations and size of the defect (p value 0.05 for all the parameters). Results: Postoperative mortality was zero, with no statistically significant differences of the duration of the postoperative hospitalization between the two groups p 0.05. A total of 34 early reoperations were required for hematoma, skin necrosis, seroma, wound suppuration, and intestinal obstruction, with no statistically significant difference between the two groups (p 0.05 for the overall and separate incidence of each complication). The onlay placement of the mesh was associated with a later removal of the superficial drains p 0.0001 with a larger proportion of the patients who were discharged without removing the drains (group A 2/62 versus group B 141/168, p 0.0001). Conclusions: Both the onlay and the retromuscular sublay placement of polypropylene meshes may be used with good results for the treatment of midline incisional hernias. The lack of a supplementary early morbidity after the retromuscular sublay repair is an argument for a more frequent use of this technique which offers a supplementary protection against infection.

Examination of abdominal wall perfusion using varying suture techniques for midline abdominal laparotomy closure.

BACKGROUND: With a growing interest in the primary prevention of incisional hernias, it has been hypothesized that different suturing techniques may cause various levels of tissue ischemia. Using ICG laser-induced fluorescence angiography (ICG-FA), we studied the effect of different suture materials and closure techniques on abdominal wall perfusion. METHODS: Fifteen porcine subjects underwent midline laparotomy, bilateral skin flap creation, and three separate 7 cm midline fascial incisions. Animals underwent fascial closure with 5 different techniques: (1) Running 0-PDS® II (polydioxanone) Suture with large bites; (2) Running 0-PDS II Suture with small bites; (3) Interrupted figure-of-eight (8) PDS II Suture, (4) Running 0-barbed STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Device large bite; (5) Running 0-STRATAFIX Symmetric PDS Plus Device small bites. ICG-FA signal intensity was recorded prior to fascial incision (baseline), immediately following fascial closure (closure), and at one-week (1-week.). Post-mortem, the abdominal walls were analyzed for inflammation, neovascularity, and necrosis. RESULTS: PDS II Suture with small bites, fascial closure at the caudal 1/3 of the abdominal wall, and the 1-week time period were all independently associated with increased tissue perfusion. There was also a significant increase in tissue perfusion from closure to 1-week when using small bites PDS II Suture compared to PDS II Suture figure-of-8 (p < 0.001) and a trend towards significance when compared with large bites PDS II Suture (p = 0.056). Additionally, the change in perfusion from baseline to 1 week with small bites was higher than with figure of 8 (p = 0.002). Across all locations, small bite PDS II Suture has greater total inflammation than figure of 8 (p < 0.001). CONCLUSIONS: The results suggest that the small bite technique increases abdominal wall perfusion and ICG-FA technology can reliably map abdominal wall perfusion. This finding may help explain the reduced incisional hernia rates seen in clinical studies with the small bite closure technique.

Mesh fixation techniques in primary ventral or incisional hernia repair.

BACKGROUND: The use of a mesh in primary ventral or incisional hernia repair lowers the recurrence rate  and is the accepted standard of care for larger defects. In laparoscopic primary ventral or incisional hernia repair the insertion of a mesh is indispensable. Different mesh fixation techniques have been used and refined over the years. The type of fixation technique is claimed to have a major impact on recurrence rates, chronic pain, health-related quality of life (HRQOL) and complication rates. OBJECTIVES: To determine the impact of different mesh fixation techniques for primary and incisional ventral hernia repair on hernia recurrence, chronic pain, HRQOL and complications. SEARCH METHODS: On 2 October 2020 we searched CENTRAL, MEDLINE (Ovid MEDLINE(R)) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)), Ovid Embase, and two trials registries. We also performed handsearches, and contacted experts from the European Hernia Society (EHS). SELECTION CRITERIA: We included randomised controlled trials (RCTs) including adults with primary ventral or incisional hernia that compared different types of mesh fixation techniques (absorbable/nonabsorbable sutures, absorbable/nonabsorbable tacks, fibrin glue, and combinations of these techniques). DATA COLLECTION AND ANALYSIS: We extracted data in standardised piloted tables, or if necessary, directly into Review Manager 5. We assessed risks of bias with the Cochrane 'Risk of bias' tool. Two review authors independently selected the publications, and extracted data on results. We calculated risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes. For pooling we used an inverse-variance random-effects meta-analysis or the Peto method in the case of rare events. We prepared GRADE 'Summary of findings' tables. For laparoscopic repair we considered absorbable tacks compared to nonabsorbable tacks, and nonabsorbable tacks compared to nonabsorbable sutures as key comparisons. MAIN RESULTS: We included 10 trials with a total of 787 participants. The number of randomised participants ranged from 40 to 199 per comparison. Eight studies included participants with both primary and incisional ventral hernia. One study included only participants with umbilical hernia, and another only participants with incisional hernia. Hernia size varied between studies. We judged the risk of bias as moderate to high. Absorbable tacks compared to nonabsorbable tacks Recurrence rates in the groups were similar (RR 0.74, 95% confidence interval (CI) 0.17 to 3.22; 2 studies, 101 participants). It is uncertain whether there is a difference between absorbable tacks and nonabsorbable tacks in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Nonabsorbable tacks compared to nonabsorbable sutures At six months there was one recurrence in each group (RR 1.00, 95% CI 0.07 to 14.79; 1 study, 36 participants). It is uncertain whether there is a difference between nonabsorbable tacks and nonabsorbable sutures in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up and chronic pain is negligible. We found no study that assessed HRQOL. Absorbable tacks compared to absorbable sutures No recurrence was observed at one year (very low certainty of evidence). Early postoperative pain was higher in the tacks group (VAS 0 - 10: MD -2.70, 95% CI -6.67 to 1.27; 1 study, 48 participants). It is uncertain whether there is a difference between absorbable tacks compared to absorbable sutures in early postoperative pain because the certainty of evidence was very low. The MD for late follow-up pain was -0.30 (95% CI -0.74 to 0.14; 1 study, 48 participants). We found no study that assessed HRQOL. Combination of different fixation types (tacks and sutures) or materials (absorbable and nonabsorbable) There were mostly negligible or only small differences between combinations (e.g. tacks plus sutures) compared to a single technique (e.g. sutures only), as well as combinations compared to other combinations (e.g. absorbable sutures combined with nonabsorbable sutures compared to absorbable tacks combined with nonabsorbable tacks) in all outcomes. It is uncertain whether there is an advantage for combining different fixation types or materials for recurrence, chronic pain, HRQOL and complications, because the evidence certainty was very low or low, or we found no study on important outcomes. Nonabsorbable tacks compared to fibrin sealant The two studies showed different directions of effects: one showed higher rates for nonabsorbable tacks, and the other showed higher rates for fibrin sealant. Low-certainty evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Absorbable tacks compared to fibrin sealant One recurrence in the tacks group and none in the fibrin sealant group were noted after one year (low certainty of evidence). Early postoperative pain might be slightly lower using tacks (VAS 0 - 100; MD -12.40, 95% CI -27.60 to, 2.80;1 study, 50 participants; low-certainty evidence). The pattern of pain and HRQOL course over time (up to 1 year) was similar in the groups (low certainty of evidence). AUTHORS' CONCLUSIONS: Currently none of the techniques can be considered superior to any other, because the certainty of evidence was low or very low for all outcomes.

Postoperative ileus after laparoscopic primary and incisional abdominal hernia repair with intraperitoneal mesh (DynaMesh®-IPOM versus Parietex™ Composite): a single institution experience.

PURPOSE: Laparoscopic primary or incisional abdominal hernia repair with intraperitoneal mesh placement is a well-accepted and safe technique. Evidence for complications however remains inconclusive, and little is known about the occurrence of postoperative ileus secondary to postoperative intra-abdominal adhesions with different types of IPOM meshes used. Therefore, we retrospectively compared the occurrence of postoperative ileus between two of the different meshes used in our center. METHODS: Three hundred seventy-five patients who underwent ventral hernia repair with intraperitoneal mesh placement, either with a DynaMesh®-IPOM (FEG Textiltechnik mbH, Aachen, Nordrhein-Westfalen, Germany) or a Parietex™ Composite mesh (Medtronic, Minneapolis, MN, USA), at the Heilig-Hart Hospital in Lier (Antwerp, Belgium) between 2012 and 2017 were retrospectively compared with regard to the occurrence of postoperative ileus until 6 weeks postoperatively. Baseline demographics and clinical data up to 6 weeks postoperatively of the patients in the two mesh groups are provided. RESULTS: The DynaMesh®-IPOM mesh group was associated with a significantly higher incidence of postoperative ileus compared with the Parietex™ Composite mesh group with a cutoff limit at postoperative day 1 (n = 17, 6.8% vs. n = 0, 0.0%; P = 0.003) and postoperative day 4 (n = 13, 5.2% vs. n = 0, 0.0%, P = 0.006), even with a mesh surface area of ≤ 300 cm2 and when both meshes were fixated with the same method of fixation (Securestrap™) with a cutoff limit for postoperative ileus at postoperative day 1 (n = 4, 7.7% vs. n = 0, 0.0%; P = 0.013) and postoperative day 4 (n = 3, 5.8% vs. n = 0, 0.0%, P = 0.040). Of the 17 patients with a postoperative ileus, 9 (52.9%) had a suspicion of adhesive small bowel obstruction on CT scan (P = 0.033) with definitive confirmation of small bowel adhesions with the DynaMesh®-IPOM mesh at laparoscopy in 2 patients. CONCLUSION: Our results confirm current literature available regarding postoperative ileus secondary to postoperative intra-abdominal adhesions with the DynaMesh®-IPOM mesh. However, further research with well-designed, multicenter randomized controlled studies to evaluate the use and related complications of these meshes is needed.

Hernia Repair Strength Enhanced With Antioxidants.

BACKGROUND: Incisional hernia is one of the most common complications of abdominal surgery, and repairs are associated with significant recurrence rates. Mesh repairs are associated with the best outcomes, but failures are not uncommon. Doxycycline has been demonstrated to enhance mesh hernia repair outcomes with associated increases in collagen deposition and improved tensiometric strength. This study compares the outcomes of incisional hernia repair with doxycycline administration and the antioxidant tempol. MATERIALS AND METHODS: Twenty-eight male Sprague Dawley rats underwent a midline hernia creation and an intraabdominal polypropylene mesh repair. The animals were administered saline, doxycycline, tempol, or both, daily for 8 wk. The abdominal wall was harvested at 8 wk and tensiometric strength and biochemical analysis was performed. RESULTS: The tensiometric strength of the repair was increased in all experimental groups. Collagen type 1 deposition was increased, and collagen type 3 deposition was decreased in each of the experimental groups relative to control. There was no difference in MMP-2 and MMP-9 levels between control and experimental groups. CONCLUSIONS: The hernia repair strength is equally enhanced with the administration of doxycycline or tempol. Dual therapy provided no benefit over treatment with either single agent. All treatment groups had an increase in collagen type 1:3 ratios, but the mechanism is not well understood. The benefits of antioxidant treatment following hernia repair are similar to treatment with doxycycline. Given the high frequency of incisional hernia repair failures, this study has implications for improving outcomes following ventral hernia repair through the use of either doxycycline or antioxidant therapy.

Effect of Fibrin Sealant on Seroma Formation Post-Incisional Hernia Repair.

Background: Development of seroma after incisional hernia repair is a common complication. Our study aims to compare the outcomes of sublay incisional hernia repairs with or without spray instillation of fibrin glue. Methods: We enrolled fifty patients undergoing incisional hernia repair. In all patients a suction drain was placed in the subcutaneous space. In one group (FG) 4 ml fibrin glue was instilled in the subcutaneous space. In the control group (C) patients did not receive any prevention measure. Wounds fluids were collected on post-operative day 1 (POD) and once daily until drain removal. All patients were followed up by ultrasound on POD 15, 20, 40, 60. Results: Drain fluid production, even if in significantly greater amount in the C group (p 0.01) as compared with the FG group, decreased after POD 1 in both groups. Drain was removed on POD-5 in 80% of FG patients and in 36% of C patients (p 0.01). No infective or bleeding complications were detected. In group FG average hospital stay was of 5.5 ÃÂ+- 2 days versus 7.1 +- 1.5 days in group C (p 0.01). At ultrasounds examination, seroma development was similar among two groups. Conclusions: Spray instillation of fibrin glue during the surgical repair reduces amount of drained fluid and hospital stay without increasing surgical complications. However, seroma occurrence was not significantly reduced.

[Treatment of postoperative ventral hernias with the use of mesh implants made of titanium thread]. / Lechenie posleoperatsionnykh ventral'nykh gryzh s ispol'zovaniem setchatykh implantov iz titanovoi niti.

AIM: Study of the results of the use of titanium thread mesh implants in the treatment of postoperative ventral hernias. METHODS: The study included 84 patients with postoperative ventral hernias. All performed open-access prosthetic hernioplasty. 2 groups were formed: the main group consisted of 32 patients who used a mesh implant made of titanium thread as an implant, the comparison group consisted of 52 patients whose hernioplasty was performed using a polypropylene mesh implant. There were no statistically significant differences between groups of patients by age, gender, average body mass index, risk class of anesthesia (ASA), size and location of hernias. RESULTS: The frequency of postoperative complications in the main group was 6.2%, in the comparison group - 3.8%. There were no statistically significant differences in this indicator between the groups. At the time of discharge from the hospital, the level of plasma C-reactive protein in patients of the main group was significantly lower than in patients of the comparison group. CONCLUSION: The use of titanium thread mesh implants in the treatment of postoperative ventral hernias is accompanied by a less inflammatory response of the body to the implant and does not lead to an increase in the frequency of postoperative complications.

Indications and Outcomes of a Cross-Linked Porcine Dermal Collagen Mesh (Permacol) for Complex Abdominal Wall Reconstruction: A Multicenter Audit.

INTRODUCTION: To reduce the occurrence of complications in the setting of high-risk patients with contaminated operative field, a wide range of biologic meshes has been developed. Yet, few series have reported outcomes after abdominal wall repair (AWR) using such meshes. Permacol is an acellular porcine dermal collagen matrix with a cross-linked pattern. This study reports short- and long-term outcomes after AWR for incisional hernia using Permacol. MATERIALS AND METHODS: All consecutive patients undergoing single-stage open AWR using Permacol mesh at eight university hospitals were included. Mortality, complication and hernia recurrence rates were assessed. Independent risk factors for complications and hernia recurrence were identified with logistic regression and Fine and Gray analysis, respectively. RESULTS: Overall, 250 patients underwent single-stage AWR with Permacol. Nearly 80% had a VHWG grade 3 or 4 defect. In-hospital mortality and complication rates were 4.8% (n = 12) and 61.6% (n = 154), respectively. Reintervention for complications was required for 74 patients (29.6%). Mesh explantation rate was 4% (n = 10). Independent risk factors for complications were smoking, defect size and VHWG grade. After a mean follow-up time of 16.8 months (± 18.1 months), 63 (25.2%) experienced hernia recurrence. One-, 2- and 3-year RFS were 90%, 74% and 57%, respectively. Previous AWR, mesh location and the need for reintervention were independent predictors of hernia recurrence. DISCUSSION: Single-stage AWR is feasible using Permacol. Mortality and complication rates are high due to patients' comorbidities and the degree of contamination of the operative field. Given the observed recurrence rate, the benefit of biologics remains to be ascertained.

Abdominal skin tensile strength in aesthetic and massive weight loss patients and its role in ventral hernia repair.

BACKGROUND: Clarifying the biomechanics of abdominal skin could lead to different uses for this tissue such as the ventral repair of hernias in patients with excess skin and incisional hernias. The objective of this study was to compare the maximum tensile strength of abdominal skin to commercial meshes and to verify whether or not it varies between aesthetic patients and massive weight-loss patients. METHODS: Experimental cross-sectional study. Skin samples sized 32 × 20 mm were taken from 15 abdominoplasties and 10 panniculectomies. The skin specimens were analyzed in vertical and horizontal tensile strength tests. Results were compared between the two groups including their traction directions. Commercial meshes were also tested. The results were analyzed using the Generalized Estimating Equation. RESULTS: The maximum tensile strength supported vertically by abdominal dermis was 403.5 ± 27.4 N in the abdominoplasty group and 425.9 ± 33.9 N in the panniculectomy group. Horizontally, the values were 596.5 ± 32.2 N and 612.5 ± 43.9 N respectively. The strengths between traction directions were significantly different (p < 0.001). There were no differences between the groups with regard to the maximum tensile strength (p = 0.472). Tested commercial meshes had the following values: polypropylene 104.6 N, low-weight polypropylene 54.4 N, polytetrafluorethylene (PTFE) 82.2 N, and hydrated porcine small-intestinal submucosa 60.0 N. CONCLUSION: In our study, the tensile strength of the tested human abdominal dermis samples, both aesthetic and post-bariatric, was superior to the commercial meshes. Therefore, in selected cases, abdominal dermis could be an alternative tool in abdominal reconstruction during panniculectomies with concomitant hernia repair.

Laparoscopic Ventral Hernia Repair with a Non-Woven Hernia Mesh.

INTRODUCTION: Laparoscopic ventral hernia repair is a commonly performed procedure with a variety of mesh options. A relatively new mesh option is a non-woven polypropylene mesh with a silicone barrier designed for intraabdominal placement. This non-woven randomly oriented polypropylene microfiber hernia mesh may have benefits with potentially better biocompatibility compared with other ventral hernia repair mesh options. MATERIALS AND METHODS: A clinical quality improvement (CQI) program was initiated for ventral hernia patients to better measure and improve outcomes. From March 2013 to September 2015, 62 laparoscopic ventral hernia repairs were performed with this non-woven polypropylene mesh on 61 patients (one patient had two separate hernia repairs). Attempts were made to obtain long-term (> 2 years) follow up. RESULTS: There were 36 females and 25 males. The average age was 58.7 years (range 21-85). The average body mass index (BMI) was 36.2 (range 21.4-62.4). There were 51 (82%) incisional hernias and 11 (18%) primary hernias. There were 29 (47%) recurrent hernias. Mean hernia size was 83.4cm2 (range 1-400) and mean mesh size was 508.5cm2 (range 144-936). The mean operating room (OR) time was 108.2 minutes (range 38-418). The mean length of hospital stay was 2.7 days (range 0-13). There was one intraoperative complication-an injury to an inferior epigastric vessel that had a minor postoperative bleed that was self-limiting and required no treatment. There was one postoperative death due to aspiration on postoperative day #4. There has been one recurrence (1.6%) with long-term follow up. There were two patients (3.2%) with suture site pain postoperatively that resolved with suture site injections of local anesthetic in the clinic. There were no patients that required rehospitalization within 30 days after surgery. There were no mesh-related complications and no incidence of mesh removal was required. CONCLUSION: The results for laparoscopic ventral hernia repair, using a relatively new non-woven randomly oriented polypropylene microfiber mesh, are good with long-term follow up completed in the majority of patients. More experience with this type of mesh could generate evidence for the benefits of this mesh material in laparoscopic ventral hernia repair.

Laparoscopic Repair of Small Ventral Hernias Using the "Ventralex™ Hernia Patch".

Laparoscopy of abdominal wall defects becomes more and more actual, considering the well-known advantages of minimally invasive surgery, and the reduced incidence of post-operative ventral infections and recurrence rates compared to the the open repair with or without mesh. We hereby present the technique of the laparoscopic repair of small ventral hernias (defect 2 centimetres), using the Ventralex mesh, which is bi-faceted, polypropylene and PTFE, circular preformed, it has 8 centimeters in diameter, fixated with 4 transparietal sutures. The mesh is created for open surgery but it is placed in the intraperitoneal cavity. This technique was used for 28 patients,16 women and 12 men, with an average age of 53,3 years (29-72 years), consisting of: 22 umbilical hernias (UH), 2 epigastric hernias (EH), one left-side Spiegelian hernia, one incisional hernia after an open surgery for an umbilical hernia with a Ventralex mesh, and 2 trocar eventrations (TE) after a laparoscopic cholecystectomy. Mean operating time was 52 minutes (42-70 minutes), post-operative hospital stay of 1,8 days (1-5 days). The main advantages are: circular preformed mesh, diameter of 8 centimeters, transfascial suture fixation, correct mesh placement and unfolding may be verified by laparoscopy, reduced costs. The technique is easy to reproduce.

Comparison of biological and alloplastic meshes in ventral incisional hernia repair.

PURPOSE: The aim of our retrospective analysis was to compare the results of incisional hernia repair by porcine small intestinal submucosa-derived (SIS) meshes with those obtained by alloplastic polypropylene-based (PP) meshes in comparable surgical indications by matched-pair design. We hypothesized that in incisional hernia, SIS mesh repair is associated with fewer recurrences and SSO than PP mesh repair in incisional hernias. METHODS: Twenty-four matched pairs (SIS vs. PP mesh repair between 1 January 2005 and 31 December 2013) were identified by matching criteria: gender, age, comorbidities, body mass index, EHS hernia classification, mesh implantation technique, CDC wound classification, and source of contamination/primary surgery leading to incisional hernia. Minimal follow-up time was 24 months. Means and standard deviations were compared by paired t test; categorial data were compared by McNemar's test. Poisson's distribution and negative binominal distribution were employed to detect significant correlation. RESULTS: There were no statistically significant differences between both groups in the pre- and perioperative factors and the follow-up times. There were significantly more wound complications (19 vs. 12, p = 0.041), longer hospital stay (22.0 ± 6.3 vs. 12.0 ± 3.1 days, p = 0.010), and significantly more recurrent hernias (25 vs. 12.5%, p = 0.004) after SIS mesh repair. Both the Poisson's distribution and the negative binominal distribution unveiled significantly more complication points (3-6 vs. 1-2) per month after SIS mesh repair. CONCLUSION: There is no advantage of SIS meshes compared to PP meshes in incisional hernia repair with different degrees of wound contamination in this matched-pair analysis. Further prospective and randomized trials or at least registry studies such as the EHS register with standardized and defined conditions are warranted.

Unidirectional barbed sutures as a novel technique for laparoscopic ventral hernia repair.

BACKGROUND: Incisional hernias remain a significant complication of abdominal surgeries. Primary closure of the hernia defect has been suggested to improve long-term abdominal wall function. However, this can be technically challenging and time consuming. This study describes laparoscopic use of non-absorbable barbed sutures in primary closure of hernia defects in addition to intraperitoneal mesh. METHODS: Patients who underwent laparoscopic primary ventral hernia repair with mesh were prospectively reviewed. Two groups were defined: Operations performed with barbed sutures for primary closure in addition to mesh and operations with only mesh without defect repair. The surgical technique involved running the hernia defect with a 2-polypropylene non-absorbable unidirectional barbed suture and subsequently fixing the mesh intraperitoneally with tacks. In both groups, a single transfascial centering suture was also utilized. RESULTS: Twenty-eight cases with barbed suture and mesh reinforcement and 29 cases with mesh-only were identified. The average dimensions of the ventral hernia defects were 57.8 (6-187) and 44.6 cm(2) (9-156) in the barbed suture with mesh and mesh-only group, respectively, p = 0.23. Median operating time was 78 min (range 35-187 min) in the barbed suture with mesh group versus 62 min (34-155 min) in the mesh-only group, p = 0.44. The median suturing time of closing the ventral hernia defect was 16 min (11-24 min). There were no differences in the pain scores. Mean follow-up for both groups was 8.2 ± 3.6 months (1-17 months) with one hernia recurrence in the mesh-only group, p = 0.41. CONCLUSIONS: The barbed suture closure system could be used for rapid and effective primary defect closure in laparoscopic ventral hernia repair in addition to intraperitoneal mesh placement. No significant difference in operating time was detected when compared to the mesh-only approach. Further evidence to support these findings and longer follow-up periods is warranted to evaluate short- and long-term complications.

Inflammatory reaction to fish oil coated polypropylene mesh used for laparoscopic incisional hernia repair: a case report.

BACKGROUND: Polypropylene meshes are widely used in hernia repairs. Hernia meshes have been developed incorporating coatings of active agents. One commercially available mesh has a fish oil coating which is promoted as having anti-inflammatory properties. We report a case, a symptomatic foreign body granuloma reaction associated with a fish oil coated polypropylene mesh, which required eventual mesh explantation. CASE PRESENTATION: A 61-year old lady with previous peptic ulcer disease underwent a laparoscopic intraperitoneal placement of mesh for incisional hernia utilising a fish oil coated polypropylene mesh. The patient presented 3 months after the procedure complaining of dyspepsia and pain at the operative site. There was no discharge. The patient was managed conservatively. She presented 10 months post-operatively with progressively worsening symptoms and a hard palpable mass in the epigastrium. Abdominal laparoscopy revealed dense adhesive disease around the mesh with exudates. Adhesiolysis, mesh explantation and a partial gastrectomy was performed. Histopathological examination revealed a foreign body granuloma formation to the mesh. CONCLUSION: In-vivo studies looking at intraperitoneal mesh placement with fish oil coatings including data on surgical outcomes such as fistula and adhesive characteristics are scarce in the literature. Further monitoring and studies are required to investigate the safety and efficacy profile of this mesh type in in-vivo models.

Polyvinylidene Fluoride Mesh (PVDF, DynaMesh®-IPOM) in The Laparoscopic Treatment of Incisional Hernia: A Prospective Comparative Trial versus Gore® ePTFE DUALMESH® Plus.

BACKGROUND: Laparoscopic approach is now generally accepted for the treatment of incisional hernia. The ideal mesh is still to be found. The aim of this study is to compare the well-known Gore® DUALMESH® Plus (WL Gore & Associates, Flagstaff, AZ) to a new prosthesis, the DynaMesh®-IPOM (FEG Textiltechnik GmbH, Aachen, Germany), to clinically verify its potential benefits in the laparoscopic treatment of incisional hernia. MATERIALS AND METHODS: Comparing the results of the laparoscopic treatment of two groups of patients affected by incisional hernia using Gore® DUALMESH® Plus and DynaMesh®-IPOM. RESULTS: There were 45 females and 31 males, with age variable from 21 to 84 years of age. The two groups were well matched for age (median age 60 years for group A and 57.6 years for group B-p=0.44) and sex (28F and 17M group A and 13 F and 18 M group B-p=0.008), while median BMI resulted slightly higher in group B (26.12 group A and 29.74 group B-p=0.001). The median size of the defect was similar in the two groups (87.5 mm group A and 83.4 mm for group B-p=0.83), while the median operating time was slightly longer in group A (77 min group A and 67 min group B-p=0.44). No difference in the length of hospital stay was evidenced between the two groups (3.19 days for group A and 3 days for group B-p=0.74). Time to return to physical activity was similar between the two groups (13.46 days for group A and 12.7 days for group B-p=0.32). Minor complications occurred in 15 cases (19.7%): seromas (7 cases), prolonged ileus (6 cases), and hemoperitoneum (2 cases), without significant difference in the incidence of such complications in the two groups. Five recurrences (6.5% of cases) occurred. No differences in the recurrence rate was noted between the two groups (3 cases/7% for group A and 2 cases/6% for group B-p=00.7). CONCLUSIONS: DynaMesh®-IPOM proved to be a safe and effective mesh for the laparoscopic repair of incisional hernia even when compared to DUALMESH® Plus.

Fibroblast matrix implants-a better alternative for incisional hernia repair?

The standard surgical procedure for abdominal hernia repair with conventional prosthetic mesh still results in a high recurrence rate. In the present study, we propose a fibroblast matrix implant (FMI), which is a three-dimensional (3D) poly-L-lactic acid scaffold coated with collagen (matrix) and seeded with fibroblasts, as an alternative mesh for hernia repair. The matrix was seeded with fibroblasts (cellularized) and treated with a conditioned medium (CM) of human Umbilical Cord Mesenchymal Stem Cells (hUC-MSC). Fibroblast proliferation and function were assessed and compared between treated with CM hUC-MSC and untreated group, 24 h after seeding onto the matrix (n= 3). To study the matricesin vivo,the hernia was surgically created on male Sprague Dawley rats and repaired with four different grafts (n= 3), including a commercial mesh (mesh group), a matrix without cells (cell-free group), a matrix seeded with fibroblasts (FMI group), and a matrix seeded with fibroblasts and cultured in medium treated with 1% CM hUC-MSC (FMI-CM group).In vitroexamination showed that the fibroblasts' proliferation on the matrices (treated group) did not differ significantly compared to the untreated group. CM hUC-MSC was able to promote the collagen synthesis of the fibroblasts, resulting in a higher collagen concentration compared to the untreated group. Furthermore, thein vivostudy showed that the matrices allowed fibroblast growth and supported cell functionality for at least 1 month after implantation. The highest number of fibroblasts was observed in the FMI group at the 14 d endpoint, but at the 28 d endpoint, the FMI-CM group had the highest. Collagen deposition area and neovascularization at the implantation site were observed in all groups without any significant difference between the groups. FMI combined with CM hUC-MSC may serve as a better option for hernia repair, providing additional reinforcement which in turn should reduce hernia recurrence.

ONLAY VERSUS RIVES-STOPPA TECHNIQUES IN THE TREATMENT OF INCISIONAL HERNIAS.

BACKGROUND: In the surgical correction of large incisional hernias, the use of a prosthesis is essential in most cases regardless of the technique chosen. The preference is for the polypropylene prosthesis. AIMS: To compare the onlay and Rives-Stoppa techniques in the correction of incisional hernias, their immediate results, complications, advantages, and disadvantages. METHODS: Two groups of patients with incisional hernias were analyzed, submitted to the onlay (19 patients) and Rives-Stoppa (17 patients) techniques, and that used polypropylene prostheses. General epidemiological variables, perioperative data variables, and postoperative complications were assessed. RESULTS: The patients' epidemiologic profile was similar between both groups. The majority were women (58.4%), with a mean age of 65.5 years and a previous mean body mass index of 41.5 kg/m². The Rives-Stoppa technique was employed in most patients (52.7%). Those submitted to the onlay technique had longer abdominal drainage time and longer hospital stay, as well as a higher incidence of seromas and surgical wound infection. CONCLUSIONS: The incisional herniorrhaphy technique with the placement of a pre-peritoneal polypropylene mesh by the Rives-Stoppa technique was superior to the onlay due to lower rates of drain use, hospital stay, and postoperative complications.

Repair of a Pulmonary Hernia after Thoracotomy with an Intrapleural Mesh: a Case Report.

Pulmonary hernias are rare. They can be congenital, but mostly are acquired. Usually asymptomatic, they are diagnosed on physical examination or, incidentally, on imaging exams. Surgical treatment is required for large, increasing, or symptomatic hernias, and incarcerated or strangulated ones. This is a clinical case of a symptomatic postoperative pulmonary hernia. It occurred two years after a posterolateral thoracotomy for the resection of an intercostal myxolipoma. The tumor was resected en bloc with a partial segment of the 10th left rib and immediate reconstruction was made with an onlay polypropylene mesh. The postoperative hernia was successfully treated with a double-faced mesh of polypropylene and ePTFE. This surgery provided a functional and aesthetic enhancement for the patient, greatly improving his quality of life. This approach is, therefore, considered safe and effective.