Lateral incisional hernia. EVEREG registry analysis.

BACKGROUND: The aim of this study is to analyze the data collected on lateral incisional hernias (LIH) in the National Incisional Hernia Registry (EVEREG) and assess current practices and outcomes in LIH repair. METHODS: A retrospective cohort study was conducted using LIH data recorded over 10 years (2012-2022). Comorbidities, hernia characteristics, short-term complications, and recurrences were studied, along with their association with the type of approach used, either open or laparoscopic, in elective surgery. RESULTS: 1742 LIH cases were studied. According to the EHS classification, these included L1 409 (23.5%), L2 388 (22.3%), L3 565 (32.4%), L4 150 (8.6%) and combined 230 (13.2%). An open approach was performed in 1528 (87.7%) cases and laparoscopic in 214 (12.3%). The median age was 66 ± 12.45 years, with a majority of males, 934 (53.6%). The median body mass index was 29 ± 5.18 kg/m2. The most observed comorbidity was arterial hypertension (957 patients, 55%). A specialist was present in 638 interventions (56%). The 24-month follow-up was 17.9%, and recurrence in those cases was 27.2%, with a higher incidence when there was no specialist present during the intervention, onlay mesh position, and larger defect size. CONCLUSIONS: Surgery for LIH is common, although laparoscopic approach remains infrequent. Furthermore, it is associated with a high percentage of recurrences that increases when there is no specialist in abdominal wall surgery present.

The evolution of incisional hernia repair in Spain. A comparative analysis of results from the EVEREG registry.

BACKGROUND: The aim of this study was to assess the utility of the EVEREG registry in evaluating the evolution of surgical treatment for incisional hernia and its outcomes in Spain by comparing data from 2 study periods. METHODS: A retrospective comparative analysis of hernia surgeries performed between 2011 and 2015 (first period) and between 2017 and 2022 (second period) was conducted using data collected from the EVEREG registry. RESULTS: Statistically significant differences were observed in the second cohort, including: a decrease in minimally invasive procedures (11.7% vs 8.2%; P < .001), an increase in emergency surgeries for males (31.7% vs 41.2%; P = .017), an increase in trocar hernia repairs (16% vs 26.2%; P < .0001), a reduction in suture repairs (2.8% vs 1.5%; P < .0001), and an increase in retromuscular techniques (36.4% vs 52.4%; P < .001) in open surgery with mesh. In elective surgery, there was a decrease in the average length of stay (4.9 vs 3.8 days; P < .0001), the percentage of complications (27.9% vs 24.0%; P < .0001), reoperations (3.5% vs 1.4%; P < .0001), and mortality (0.6% vs 0.2%; P = .002). Long-term outcomes included a decrease in recurrences after 12 months (20.7% vs 14.5%; P < .0001) and in chronic pain (13.7% vs 2.5%; P < .0001) and chronic infections (9.1% vs 14.5%; P < .0001) after 6 months. CONCLUSION: In recent years, there has been a significant improvement in the outcomes of incisional hernia treatment. The registry serves as a fundamental tool for assessing the evolution of hernia treatment and enables the identification of key areas for improvement and the evaluation of treatment outcomes.

Ventral hernia repair in high-risk patients and contaminated fields using a single mesh: proportional meta-analysis.

PURPOSE: The use of mesh is a common practice in ventral hernia repair (VHR). Lack of consensus on which prosthetic material works better in different settings remains. This meta-analysis aims to summarize the available evidence on hernia recurrence and complications after repair with synthetic, biologic, or biosynthetic/bioabsorbable meshes in hernias grade 2-3 of the Ventral Hernia Working Group modified classification. METHODS: A literature search was conducted in January 2021 using Web of Science (WoS), Scopus, and MEDLINE (via PubMed) databases. Randomized Controlled Trials (RCTs) and observational studies with adult patients undergoing VHR with either synthetic, biologic, or biosynthetic/bioabsorbable mesh were included. Outcomes were hernia recurrence, Surgical Site Occurrence (SSO), Surgical Site Infection (SSI), 30 days re-intervention, and infected mesh removal. Random-effects meta-analyses of pooled proportions were performed. Quality of the studies was assessed, and heterogeneity was explored through sensitivity analyses. RESULTS: 25 articles were eligible for inclusion. Mean age ranged from 47 to 64 years and participants' follow-up ranged from 1 to 36 months. Biosynthetic/bioabsorbable mesh reported a 9% (95% CI 2-19%) rate of hernia recurrence, lower than synthetic and biologic meshes. Biosynthetic/bioabsorbable mesh repair also showed a lower incidence of SSI, with a 14% (95% CI 6-24%) rate, and there was no evidence of infected mesh removal. Rates of seroma were similar for the different materials. CONCLUSIONS: This meta-analysis did not show meaningful differences among materials. However, the best proportions towards lower recurrence and complication rates after grade 2-3 VHR were after using biosynthetic/slowly absorbable mesh reinforcement. These results should be taken with caution, as head-to-head comparative studies between biosynthetic and synthetic/biologic meshes are lacking. Although, biosynthetic/bioabsorbable materials could be considered an alternative to synthetic and biologic mesh reinforcement in these settings.

European Hernia Society guidelines on management of rectus diastasis.

BACKGROUND: The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been described. This article reports on the European Hernia Society (EHS) Clinical Practice Guideline for RD. METHOD: The Guideline group consisted of eight surgeons. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done in November 2018 and updated in November 2019 and October 2020. Nine Key Questions (KQs) were formulated. RESULTS: Literature reporting on the definition, classification, symptoms, outcomes and treatments was limited in quality, leading to weak recommendations for the majority of the KQs. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is suggested based on the width of muscle separation, postpregnancy status and whether or not there is a concomitant hernia. Impaired body image and core instability appear to be the most relevant symptoms. Physiotherapy may be considered before surgical management. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD with concomitant midline hernias. CONCLUSION: RD should be defined as a separation of rectus muscles wider than 2 cm and a new classification system is suggested.

The management of RD is controversial. These guidelines are intended to provide a consensus about the exact definition, the correct way of measurement and diagnosis, a classification system, the main symptoms, and a systematic review of non-surgical and surgical treatments to achieve the best results for patients with this pathology. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is proposed. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD in those with concomitant midline hernias.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG).

AIM: To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients. METHODS: All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed. RESULTS: During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m2. ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004). CONCLUSION: CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen.

PURPOSE: To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA) in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible materials to be used. METHODS: The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument. RESULTS: For many of the Key Questions that were researched, there were no high quality studies available. While some strong recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical expertise guidance which are distinct from recommendations that have been formally categorized using GRADE. RECOMMENDATIONS: When considering the OA, dynamic closure techniques should be prioritized over the use of static closure techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance statement concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition, the role of the abdominal girdle seems limited to very selected patients.

[Urachal sinus: an unusual cause of recurrent umbilical discharge in adults]. / Uracosinus: una causa poco frecuente de onfalitis recurrente en adultos.

Urachal sinus is a rare congenital anomaly due to incomplete closure the urachus in the umbilical region, it is very rare in adults. 47-year-old male who arrived at our Emergency Department with recurrent umbilical discharge. Not response medical treatment (oral antibiotic and drainage). Abdominal computerized tomography scan confirmed the urachal sinus with omphalitis. Surgical complete excision with omphalectomy was performed. Any complications in the postoperative was observed.

[Clinical and functional results after Laparoscopic fundoplication. Prospective evaluation]. / Resultados clínicos y funcionales después de funduplicatura laparoscópica. Evaluación prospectiva.

OBJECTIVE: To prospectively assess the medium- and long-term clinical and functional results in consecutive patients undergoing laparoscopic procedures for gastroesophageal reflux. PATIENTS AND METHOD: The series included the interventions performed or assisted by the first author in 325 patients referred for surgical evaluation between December 1992 and June 2000. Forty patients were excluded from the study because they did not fulfil the inclusion criteria for laparoscopic surgery. A further 20 patients who underwent laparoscopic surgery were excluded because they required conversion to open surgery. Thus, 265 patients were included in the study. One hundred ninety-six total fundoplications (Nissen-Rossetti) and 69 partial fundoplications(42 posterior-Toupet and 27 anterior-Dor) were performed. The surgical technique employed was a slight modification of that described by Dallemagne et al with five-trocars. Preoperative evaluation was established by clinical features, endoscopy with biopsy, barium contrast radiography, esophageal manometry and esophageal pH monitoring. RESULTS: The mean follow-up was 47.1 3.3 months (range: 4-92 months). Heartburn, regurgitation, and dysphagia were relieved in 92.5%, 97.7%, and 88.1% of patients respectively. Complete relief of symptoms was achieved in all patients who presented preoperative respiratory symptoms as a complication of gastroesophageal reflux. Esophagitis healed in 98.2% of patients with preoperative esophagitis. Correction of lower esophageal sphincter pressure and lower esophageal sphincter length were statistically significant compared with preoperative status (p = 0.006 and p = 0.003, respectively). Pre- and postoperative differences in the percentage of patients with a pH < 4 in 24-hour ambulatory esophageal pH monitoring were also significant (p = 0.005), confirming correction of acid reflux. Morbidity appeared in 6.7% of patients and there was no mortality. Conversion to open procedures was required in 7.5%. The mean operative time was 115 6.3 minutes. CONCLUSIONS: These preliminary results suggest that when performed by experienced surgeons laparoscopic fundoplication provides an excellent alternative in selected patients with gastroesophageal reflux. Both medium- and long-term clinical and functional results, as well as morbidity, were satisfactory and were similar to those of open fundoplication.

Survival after prehospital advanced life support in severe trauma.

The aim of this study was to assess the influence of prehospital advanced life support (PALS) on the survival of victims of severe trauma in our hospital. During a period of 24 months, 46 patients with severe trauma were admitted to our Emergency Department after receiving PALS; this included endotracheal intubation and ventilatory support (IVS) in 35 cases, and cardiopulmonary resuscitation (CPR) in 11. The severity of the trauma in this group of patients was confirmed by assessing the clinical condition on admission and the Glasgow Coma Scale score (mean = 4.0, median = 3), the Revised Trauma score (mean = 4.1, median = 4) and the Injury Severity Score (mean = 44.5 and median = 41 in blunt trauma; mean = 58.3 and median = 75 in penetrating trauma). The overall survival was 41%. The survival rate was 48% in patients with prehospital IVS rate and 18% in those receiving CPR. We conclude that PALS in severe trauma was able to save the lives of many patients at high risk of dying before reaching hospital.

[Massive rectal hemorrhage caused by nonspecific colonic ulcers]. / Rectorragia masiva por úlceras cólicas inespecíficas.

Nonspecific colon ulcers are a rare disease which may produce lower gastrointestinal bleeding. A history of previous nonsteroidal anti-inflammatory drugs ingestion may be recorded in most patients. The right colon is the main location, being the cecum the most frequent site. However, they may be distributed in all the large intestine, including the rectum. We present a case of lower massive gastrointestinal hemorrhage produced by nonspecific colic ulcers requiring emergency total colectomy. Although infrequent, they have to be considered in every patient with lower gastrointestinal bleeding and previous nonsteroidal anti-inflammatory drugs ingestion.