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

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

Prevention of incisional hernia after kidney transplantation: study protocol for a randomized controlled trial.

BACKGROUND: Incisional hernia is a common complication after kidney transplantation with an incidence of 1.6-18%. Concerning non-transplant patients, a recently published meta-analysis describes a reduction of the incidence of incisional hernia of up to 85% due to prophylactic mesh replacement in elective, midline laparotomy. The aim of our study is to show a reduction of the incidence of incisional hernia after kidney transplantation with minimal risk for complication. METHODS/DESIGN: This is a blinded, randomized controlled trial comparing time to incisional hernia over a period of 24 months between patients undergoing kidney transplantation and standardized abdominal closure with or without prophylactic placement of ProGrip™ (Medtronic, Fridley, MN, USA) mesh in an onlay position. As we believe that the mesh intervention is superior to the standard procedure in reducing the incidence of hernia, this is a superiority trial. DISCUSSION: The high risk for developing incisional hernia following kidney transplantation might be reduced by prophylactic mesh placement. ProGrip™ mesh features polylactic acid (PLA) microgrips that provide immediate, strong and uniform fixation. The use of this mesh combines the effectiveness demonstrated by the macropore propylene meshes in the treatment of incisional hernias, a high simplicity of use provided by its capacity for self-fixation that does not increase significantly surgery time, and safety. TRIAL REGISTRATION: ClinicalTrials.gov NCT04794582. Registered on 08 March 2021. Protocol version 2.0. (02-18-2021).

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

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

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

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

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

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

Stepwise transversus abdominis muscle release for the treatment of complex bilateral subcostal incisional hernias.

BACKGROUND: Management of subcostal incisional hernias is particularly complicated due to their proximity to the costochondral limits in addition to the lack of aponeurosis on the lateral side of the abdomen. We present our results of posterior component separation through the same previous incision as a safe and reproducible technique for these complex cases. METHODS: We present a multicenter and prospective cohort of patients diagnosed with bilateral subcostal incisional hernias on either clinical examination or imaging based on computed tomography from 2014 to 2020. The aim of this investigation was to assess the outcomes of abdominal wall reconstruction for subcostal incisional hernias through a new approach. The outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score. RESULTS: A total of 46 patients were identified. All patients underwent posterior component separation. Surgical site occurrences occurred in 10 patients (22%), with only 7 patients (15%) requiring procedural intervention. During a mean follow-up of 18 (range, 6-62), 1 (2%) case of clinical recurrence was registered. In addition, there were 8 (17%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) of the postoperative compared with the preoperative scores. CONCLUSION: Posterior component separation technique for the repair of subcostal incisional hernias through the same incision is a safe procedure that avoids injury to the linea alba. It is associated with acceptable morbidity, low recurrence rate, and improvement in patients' reported outcomes.

Outcomes of abdominal wall reconstruction in patients with the combination of complex midline and lateral incisional hernias.

BACKGROUND: The best treatment for the combined defects of midline and lateral incisional hernia is not known. The aim of our multicenter study was to evaluate the operative and patient-reported outcomes using a modified posterior component separation in patients who present with the combination of midline and lateral incisional hernia. METHODS: We identified patients from a prospective, multicenter database who underwent operative repairs of a midline and lateral incisional hernia at 4 centers with minimum 2-year follow-up. Hernias were divided into a main hernia based on the larger size and associated abdominal wall hernias. Outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score. RESULTS: Fifty-eight patients were identified. Almost 70% of patients presented with a midline defect as the main incisional hernia. The operative technique was a transversus abdominis release in 26 patients (45%), a modification of transversus abdominis release 27 (47%), a reverse transversus abdominis release in 3 (5%), and a primary, lateral retromuscular preperitoneal approach in 2 (3%). Surgical site occurrences occurred in 22 patients (38%), with only 8 patients (14%) requiring procedural intervention. During a mean follow-up of 30.1 ± 14.4 months, 2 (3%) cases of recurrence were diagnosed and required reoperation. There were also 4 (7%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) in the postoperative score compared with the preoperative score. CONCLUSION: The different techniques of posterior component separation in the treatment of combined midline and lateral incisional hernia show acceptable results, despite the associated high complexity. Patient-reported outcomes after measurement of the European Registry for Abdominal Wall Hernias Quality of Life score demonstrated a clinically important improvement in quality of life and pain.

Second Look After Retromuscular Repair With the Combination of Absorbable and Permanent Meshes.

Objective: The aim of this study is to describe the macroscopic features and histologic details observed after retromuscular abdominal wall reconstruction with the combination of an absorbable mesh and a permanent mesh. Methods: We have considered all patients that underwent abdominal wall reconstruction (AWR) with the combination of two meshes that required to be reoperated for any reason. Data was extracted from a prospective multicenter study from 2012 to 2019. Macroscopic evaluation of parietal adhesions and histological analysis were carried out in this group of patients. Results: Among 466 patients with AWR, we identified 26 patients that underwent a reoperation after abdominal wall reconstruction using absorbable and permanent mesh. In eight patients, the reoperation was related to abdominal wall issues: four patients were reoperated due to recurrence, three patients required an operation for chronic mesh infection and one patient for symptomatic bulging. A miscellanea of pathologies was the cause for reoperation in 18 patients. During the second surgical procedures made after a minimum of 3 months follow-up, a fibrous tissue between the permanent mesh covering and protecting the peritoneum was identified. This fibrous tissue facilitated blunt dissection between the permanent material and the peritoneum. Samples of this tissue were obtained for histological examination. No case of severe adhesions to the abdominal wall was seen. In four cases, the reoperation could be carried out laparoscopically with minimal adhesions from the previous procedure. Conclusions: The reoperations performed after the combination of absorbable and permanent meshes have shown that the absorbable mesh acts as a protective barrier and is replaced by a fibrous layer rich in collagen. In the cases requiring new hernia repair, the layer between peritoneum and permanent mesh could be dissected without special difficulty. Few intraperitoneal adhesions to the abdominal wall were observed, mainly filmy, easy to detach, facilitating reoperations.

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

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

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

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

Prophylactic mesh can be used safely in the prevention of incisional hernia after bilateral subcostal laparotomies.

BACKGROUND: The use of prophylactic mesh to prevent incisional hernia is becoming increasingly common in midline laparotomies and colostomies. The incidence of incisional hernia after subcostal laparotomies is lower than after midline incisions. Nevertheless, the treatment of subcostal incisional hernia is considered to be more complex. Currently, there are no published data about mesh augmentation procedures to close these laparotomies. METHODS: This was a longitudinal, prospective, cohort study of patients undergoing a bilateral subcostal laparotomy in elective operations. The mesh group was a group of patients operated consecutively between 2011 and 2013 with a prophylactic self-fixation mesh. The control group was selected from a retrospective analysis of patients operated between 2009 and 2010 and closed with a conventional protocol of 2-layer closure. The incidence of incisional hernia was recorded both clinically and radiologically for 2 years. RESULTS: A total of 57 patients were included in the control group and 58 in the mesh group. Most patients underwent gastric, hepatic, and pancreatic operations. Both groups were homogeneous in terms of their clinical and demographic characteristics. Operative time and hospital stay were similar in both groups. Both groups had a comparable rate of local and systemic complications. Ten patients (17.5%) in the control group developed an incisional hernia, and only 1 patient (1.7%) in the mesh group developed an incisional hernia (P = .0006). CONCLUSION: The incidence of incisional hernia after a conventional closure of bilateral subcostal laparotomy is significant. The use of a mesh augmentation procedure for closing bilateral subcostal laparotomies is safe and may reduce the incidence of incisional hernia.

¿Puede ser una apendicitis aguda la primera manifestación de endometriosis? / Can acute appendicitis be the first manifestation of endometrial disease?

Objetivo. Demostrar la relación entre la afectación endometriósica del apéndice cecal y el desarrollo de una apendicitis aguda. Pacientes y métodos. Presentamos una serie institucional de 8 pacientes con endometriosis apendicular diagnosticadas tras apendicectomía entre junio de 2009 y marzo de 2014. Resultados. La media de edad fue 40,6 años, 6 en edad fértil. En 5 (62,5%) la afectación endometriósica apendicular resultó única y en 3 (37,5%) múltiple, fundamentalmente en el ovario. Siete (87,5%) iniciaron los síntomas como una apendicitis aguda. Los implantes endometriósicos afectaban la capa serosa en 6 pacientes, la capa muscular en una y la grasa periapendicular en otra. Conclusión. El diagnóstico de endometriosis apendicular en mujeres con apendicitis aguda solo se puede realizar tras el examen de las piezas de apendicectomía, aunque puede ser sospechado en el contexto clínico. La laparoscopia permite un diagnóstico adecuado con exploración completa de la pelvis, la apendicectomía y el tratamiento de otras lesiones (AU)

Aim. To determine the relationship between endometriotic involvement of the appendix and the development of acute appendicitis. Patients and methods. We report a series of 8 patients with appendiceal endometriosis diagnosed after appendicectomy from June 2009 to March 2014. Results. The mean age was 40.6 years. Six patients were of reproductive age. Endometriotic appendiceal involvement alone was found in 5 patients (62.5%) and multiorgan involvement, mainly affecting the ovary, in 3 patients (37.5%). Clinical presentation was acute appendicitis in 7 patients (87.5%). Endometriotic implants involved the serous layer in 6 patients, the muscle layer in one patient, and periappendiceal fat in another patient. Conclusion. Diagnosis of appendiceal endometriosis in women with acute appendicitis can only be performed after specimen study, although it may be suspected in the clinical context. Laparoscopy allows pelvic and abdominal cavity examination, appendectomy, and the treatment of other lesions (AU)

Video-assisted laparoscopic débridement for retroperitoneal pancreatic collections: a reliable step-up approach.

Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.