Surgical Site Infiltration for Abdominal Surgery: A Novel Neuroanatomical-based Approach.

BACKGROUND: Provision of optimal postoperative analgesia should facilitate postoperative ambulation and rehabilitation. An optimal multimodal analgesia technique would include the use of nonopioid analgesics, including local/regional analgesic techniques such as surgical site local anesthetic infiltration. This article presents a novel approach to surgical site infiltration techniques for abdominal surgery based upon neuroanatomy. METHODS: Literature searches were conducted for studies reporting the neuroanatomical sources of pain after abdominal surgery. Also, studies identified by preceding search were reviewed for relevant publications and manually retrieved. RESULTS: Based on neuroanatomy, an optimal surgical site infiltration technique would consist of systematic, extensive, meticulous administration of local anesthetic into the peritoneum (or preperitoneum), subfascial, and subdermal tissue planes. The volume of local anesthetic would depend on the size of the incision such that 1 to 1.5 mL is injected every 1 to 2 cm of surgical incision per layer. It is best to infiltrate with a 22-gauge, 1.5-inch needle. The needle is inserted approximately 0.5 to 1 cm into the tissue plane, and local anesthetic solution is injected while slowly withdrawing the needle, which should reduce the risk of intravascular injection. CONCLUSIONS: Meticulous, systematic, and extensive surgical site local anesthetic infiltration in the various tissue planes including the peritoneal, musculofascial, and subdermal tissues, where pain foci originate, provides excellent postoperative pain relief. This approach should be combined with use of other nonopioid analgesics with opioids reserved for rescue. Further well-designed studies are necessary to assess the analgesic efficacy of the proposed infiltration technique.

Materials characterization of explanted polypropylene hernia mesh: Patient factor correlation.

This study quantitatively assessed polypropylene (PP) hernia mesh degradation and its correlation with patient factors including body mass index, tobacco use, and diabetes status with the goal of improving hernia repair outcomes through patient-matched mesh. Thirty PP hernia mesh explants were subjected to a tissue removal process followed by assessment of their in vivo degradation using Fourier transform infrared, differential scanning calorimetry, and thermogravimetric analysis analyses. Results were then analyzed with respect to patient factors (body mass index, tobacco use, and diabetes status) to determine their influence on in vivo hernia mesh oxidation and degradation. Twenty of the explants show significant surface oxidation. Tobacco use exhibits a positive correlation with modulated differential scanning calorimetry melt temperature and exhibits significantly lower TGA decomposition temperatures than non-/past users. Chemical and thermal characterization of the explanted meshes indicate measurable degradation while in vivo regardless of the patient population; however, tobacco use is correlated with less oxidation and degradation of the polymeric mesh possibly due to a reduced inflammatory response.

Characterization of bionanocomposite scaffolds comprised of mercaptoethylamine-functionalized gold nanoparticles crosslinked to acellular porcine tissue.

Bionanocomposite scaffolds comprised of nanomaterials and the extracellular matrix (ECM) of porcine diaphragm tissue capitalizes on the benefits of utilizing a natural ECM material, while also potentially enhancing physicomechanical properties and biocompatibility through nanomaterials. Gold nanoparticle (AuNP) bionanocomposite scaffolds were subjected to a number of characterization techniques to determine whether the fabrication process negatively impacted the properties of the porcine diaphragm tissue and whether the AuNP improved the properties of the tissue. Tensile testing and differential scanning calorimetry demonstrated that the bionanocomposite possessed improved tensile strength and thermal stability relative to natural tissue. The collagenase assay and Fourier transform infrared spectroscopy additionally confirmed that denaturation of the collagen of the ECM did not occur. The novel bionanocomposite scaffold possessed properties similar to commercially available scaffolds and will be further developed for soft tissue applications such as hernia repair through in vivo studies in an animal model.

Development and in vitro studies of a polyethylene terephthalate-gold nanoparticle scaffold for improved biocompatibility.

Polyethylene terephthalate (PET) mesh is one of the most commonly used synthetic biomaterials for tension-free hernia repair. In an effort to improve the biocompatibility of PET mesh, gold nanoparticles (AuNP) in various concentrations were conjugated to the PET surface to develop PET-AuNP scaffolds. These novel scaffolds were characterized with Fourier transform infrared spectroscopy (FT-IR), scanning electron microscopy (SEM), and differential scanning calorimetry (DSC) to assess the addition of functional groups, presence of AuNPs, and thermal stability of the modified PET mesh, respectively. The biocompatibility of the PET-AuNP scaffolds was evaluated through in vitro cell culture assays. The cellularity of cells exposed to the PET-AuNP scaffolds, as well as the scaffolds' ability to reduce reactive oxygen species, was assessed using L929 murine fibroblasts. Antimicrobial properties of AuNPs conjugated to PET mesh were tested against the bacteria Pseudomonas aeruginosa. Results from the FT-IR showed presence of COOH groups while SEM displayed bonding of AuNPs to the PET surface. DSC results indicated that the PET more than likely did not undergo any detrimental degradation due to the surface modification. Results from the in vitro studies showed that AuNPs, in optimal concentrations (1× concentrations), enhanced cellularity, reduced ROS, and reduced bacteria adhesion to PET. These studies demonstrated enhanced biocompatibility of the AuNP conjugated PET mesh over pristine PET mesh.

Absorbable versus nonabsorbable mesh repair of congenital diaphragmatic hernias in a growing animal model.

INTRODUCTION: The repair of large congenital diaphragmatic hernia frequently results in patch disruption and recurrence as patients grow in size. Absorbable meshes allow for ingrowth of endogenous tissue as they are degraded, providing a more natural and durable repair. The aim of this study was to compare the characteristics of the new diaphragmatic tissue between an absorbable biologic mesh and a nonabsorbable mesh for repairing diaphragmatic hernia in a growing animal model. METHODS: The left hemi-diaphragm of twenty 2-month-old Yucatan pigs was nearly completely resected. Small intestinal submucosa (SIS; Cook Biotech, Lafayette, IN) and expanded polytetrafluoroethylene (ePTFE; W.L. Gore & Associates, Flagstaff, AZ) were randomly assigned to cover the defect in 10 animals each, and were survived for 6 months. During necropsy, newly formed diaphragmatic tissue was evaluated and compared between the two groups. RESULTS: At necropsy, the animals had tripled their weight. Patch disruption and herniation occurred in 3 animals in the ePTFE group and none in the SIS group. The SIS mesh had better integration to the chest wall (2.8 ± 0.2 versus 1.3 ± 0.3), more muscle growth within the newly formed diaphragmatic tissue (1.9 ± 0.2 versus 0.4 ± 0.2), and less fibrotic tissue (2.1 ± 0.5 versus 3.4 ± 0.4) than ePTFE. There was no difference between SIS and ePTFE in terms of adhesion scores to the lung (2 ± 0.4 versus 2.4 ± 0.4) and liver (1.8 ± 0.3 versus 2.2 ± 0.5). CONCLUSION: SIS allows for tissue ingrowth from surrounding tissue as it degrades, providing a more durable repair with 30% less incidence of herniation in a porcine model. As the diaphragm grows, SIS resulted in a more natural repair of the defect with more tissue growth, better tissue integration, and a comparable adhesion formation to ePTFE.

Characterization of bionanocomposite scaffolds comprised of amine-functionalized gold nanoparticles and silicon carbide nanowires crosslinked to an acellular porcine tendon.

As one of the most common proteins found in the human body, collagen is regarded as biocompatible and has many properties making it ideal for soft-tissue repair applications. However, collagen matrices fabricated from purified forms of collagen are notoriously weak and easily degraded by the body. The extracellular matrix of many tissues including human dermis, porcine dermis, and porcine small intestine submucosa are often utilized instead, and several of these scaffolds are crosslinked. Crosslinking has been shown to improve the mechanical properties of collagenous tissues and increase their resistance to degradation. In this study we investigated two novel "bionanocomposite" materials in which either gold nanoparticles or silicon carbide nanowires were crosslinked to a porcine tendon. Scanning electron micrographs confirmed that the nanomaterials were successfully crosslinked to the tissues. A collagenase assay, tensile testing, flow cytometry, and bioreactor studies were also performed to further characterize the properties of these novel materials. The results of these studies indicated that crosslinking porcine diaphragm tissues with nanomaterials resulted in scaffolds with improved resistance to enzymatic degradation and appropriate biocompatibility characteristics, thus warranting further study of these materials for soft tissue repair and tissue engineering applications.

Characterization of bionanocomposite scaffolds comprised of amine-functionalized single-walled carbon nanotubes crosslinked to an acellular porcine tendon.

Carbon nanotubes (CNT) possess many unique electrical and mechanical properties that make them useful for a variety of industrial and biomedical applications. They are especially attractive materials for biomedical applications since their dimensions are similar to components of the extracellular matrix. In this study, amine-functionalized single-walled carbon nanotubes were crosslinked to an acellular porcine diaphragm tendon. The resulting bionanocomposite scaffolds were subjected to a number of materials characterization techniques including a collagenase assay, uniaxial tensile testing, modulated differential scanning calorimetry, and attenuated total reflectance Fourier transform infrared (ATR-FTIR) spectroscopy to determine whether the properties of the original extracellular matrix were altered by the treatment processes. A variety of SWCNT concentrations were investigated. While none of the conditions investigated resulted in bionanocomposites with significantly improved physicochemical properties, no detrimental effects were observed due to any of the processing steps. Future studies should be performed to determine if carbon nanotubes can influence cellular adhesion and function in order to promote rapid integration and remodeling.

Materials characterization of explanted polypropylene, polyethylene terephthalate, and expanded polytetrafluoroethylene composites: spectral and thermal analysis.

This study utilized spectral and thermal analysis of explanted hernia mesh materials to determine material inertness and elucidate reasons for hernia mesh explantation. Composite mesh materials, comprised of polypropylene (PP) and expanded polytetrafluoroethylene (ePTFE) mesh surrounded by a polyethylene terephthalate (PET) ring, were explanted from humans. Scanning electron microscopy (SEM) was conducted to visually observe material defects while attenuated total reflectance Fourier transform infrared spectroscopy (ATR-FTIR) was used to find chemical signs of surface degradation. Modulated differential scanning calorimetry (MDSC) and thermogravimetric analysis (TGA) gave thermal stability profiles that showed changes in heat of fusion and rate of percent weight loss, respectively. ATR-FTIR scans showed higher carbonyl peak areas as compared to pristine for 91% and 55% of ePTFE and PP explants, respectively. Ninety-one percent of ePTFE explants also exhibited higher C--H stretch peak areas. Seventy-three percent of ePTFE explants had higher heats of fusion while 64% of PP explants had lower heats of fusion with respect to their corresponding pristines. Only 9% of PET explants exhibited a lower heat of fusion than pristine. Seventy-three percent of ePTFE explants, 73% of PP explants, and only 18% of PET explants showed a decreased rate of percent weight loss as compared to pristine. The majority of the PP and ePTFE mesh explants demonstrated oxidation and crosslinking, respectively, while the PET ring exhibited breakdown at the sites of high stress. The results showed that all three materials exhibited varied degrees of chemical degradation suggesting that a lack of inertness in vivo contributes to hernia mesh failure.

Early results of midline hernia repair using a minimally invasive component separation technique.

A minimally invasive component separation may lead to a dynamic abdominal wall after hernia repair, with reduced complications. We present early results of our patients undergoing this technique. Five patients were selected for open midline repairs; three with chronic infections, one with a prior midline skin graft, and one who desired a primary, tension-free repair. These three males and two females had a mean age of 50.8 +/- 21.1 years and body mass index of 30.9 +/- 6.2. The mean number of previous abdominal operations was 7 +/- 3.4 and previous attempted hernia repairs were 4 +/- 2.7. All patients had a midline laparotomy with lysis of adhesions. An endoscopic component separation was then performed bilaterally. Drains were left in the dissection bed. All patients had the midline closed; four received biologic mesh underlays. Mean operative time was 227 minutes +/- 49. Mean length of stay (LOS) was 9.2 days +/- 3.6. Early median follow-up was 6 months (range 0.25-9). Two patients required postop transfusions, and two patients had mild complications of the midline wound (hematoma, infection). To date, one recurrence was diagnosed by CT scan. Early evaluation of adopting the minimally invasive (MIS) component separation demonstrates minimal complications and good initial outcomes.

Technique of laparoscopic ventral hernia repair can be modified to successfully repair large defects in patients with loss of domain.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) can be challenging in patients with large abdominal wall defects and loss of domain (LOD). When hernia contents are reduced, the pneumoperitoneum preferentially fills the sac, leaving no space for mesh manipulation. This study presents a modification for LVHR in LOD patients, as well as outcomes for a series of patients. METHODS: Between September 2002 and August 2004, 10 patients with large ventral hernias and LOD underwent attempts at LVHR. The technique is modified by placing additional trocars to allow for fixation from above the mesh. Patient data were harvested from a prospective database and analyzed. RESULTS: All hernias were recurrent in nature. Mean defect size was 626 cm(2), requiring 1 to 4 pieces of sutured Gore Dualmesh for a tension-free repair. Three patients' procedures were aborted after adhesiolysis, with concerns about missed enterotomies. All 3 underwent delayed mesh placement within the same hospitalization. Only 2 were successful. The third patient had significant bowel edema precluding mesh placement. Two patients were converted to open repairs (Rives-Stoppa and component separation). There were no mortalities, but there were 2 major complications: inferior vena cava thrombosis and transient abdominal compartment syndrome. In follow-up (7.7 months) there were 2 recurrences secondary to excision of infected mesh. CONCLUSION: It is possible to obtain a successful LVHR in patients with large defects and LOD. The technique is complex and is modified to allow for mesh fixation from above the mesh. Frequent change in patient positioning allows for visualization below the fascial defect.

Management of anastomotic leaks after Roux-en-Y bypass using self-expanding polyester stents.

BACKGROUND: To analyze the outcomes of a series of endoscopically placed polyester self-expanding polyflex stents (SEPSs) for the management of anastomotic leaks after Roux-en-Y bypass. Anastomotic leaks after gastric bypass cause significant morbidity and mortality. Covered polyester SEPSs might have a role in the treatment of these leaks. METHODS: A retrospective chart review was performed from January 2006 to November 2006 that included all acute and chronic leaks treated with SEPSs. RESULTS: A total of 6 patients were treated with stents, with a mean procedure time of 22 minutes. Of these 6 patients, 5 had acute postoperative leaks and 1 had a chronic fistula. Five patients started oral intake 1-6 days after their procedure. All acute leaks had complete healing at a median of 44 days. The patient with a chronic gastrocutaneous fistula required revisional surgery for fistula closure. In addition, 5 patients had stent migration, and 3 required stent replacement. CONCLUSION: An endoscopically placed SEPS provides a less-invasive alternative to treat acute anastomotic leaks after Roux-en-Y bypass while simultaneously allowing oral intake. The results of this case series have demonstrated this treatment to be safe and effective.

Catamenial appendicitis.

BACKGROUND: Reproductive-aged women undergoing appendectomy for suspected appendicitis have twice the rate of negative histology as age-matched men. The reason for this discrepancy is unknown. CASES: Three patients with peritoneal endometriosis and recurrent symptoms of acute appendicitis coincident with menses underwent resection of a noninflamed appendix with long-term symptom resolution. Standard pathological evaluation failed to demonstrate evidence of appendiceal endometriosis or appendicitis. Additional evaluation demonstrated a marked increase in number of mast cells in the appendiceal muscularis compared with normal appendices. CONCLUSION: The term "catamenial appendicitis" has been coined to describe these cases, and a mechanism of pathogenesis of right lower quadrant pain and nausea in patients with histologically confirmed endometriosis is proposed.

Integrated flexible endoscopy training during surgical residency.

BACKGROUND: New advances in endoscopic surgery make it imperative that future gastrointestinal surgeons obtain adequate endoscopy skills. An evaluation of the 2001-02 general surgery residency endoscopy experience at the University of Missouri revealed that chief residents were graduating with an average of 43 endoscopic cases. This met American Board of Surgery (ABS) and Accreditation Council for Graduate Medical Education (ACGME) requirements but is inadequate preparation for carrying out advanced endoscopic surgery. Our aim was to determine if endoscopy volume could be improved by dedicating specific staff surgeon time to a gastrointestinal diagnostic center at an affiliated Veterans Administration Hospital. METHODS: During the academic years 2002-05, two general surgeons who routinely perform endoscopy staffed the gastrointestinal endoscopy center at the Harry S. Truman Hospital two days per week. A minimum of one categorical surgical resident participated during these endoscopy training days while on the Veterans Hospital surgical service. A retrospective observational review of ACGME surgery resident case logs from 2001 to 2005 was conducted to document the changes in resident endoscopy experience. The cases were compiled by postgraduate year (PGY). RESULTS: Resident endoscopy case volume increased 850% from 2001 to 2005. Graduating residents completed an average of 161 endoscopies. Endoscopic experience was attained at all levels of training: 26, 21, 34, 23, and 26 mean endoscopies/year for PGY-1 to PGY-5, respectively. CONCLUSIONS: Having specific endoscopy training days at a VA Hospital under the guidance of a dedicated staff surgeon is a successful method to improve surgical resident endoscopy case volume. An integrated endoscopy training curriculum results in early skills acquisition, continued proficiency throughout residency, and is an efficient way to obtain endoscopic skills. In addition, the foundation of flexible endoscopic skill and experience has allowed early integration of surgery residents into research efforts in natural orifice transluminal endoscopic surgery.

Does a one-day course influence surgeon adoption of laparoscopic ventral herniorrhaphy?

BACKGROUND: New laparoscopic techniques introduced after residency have created a new teaching paradigm focused on animate courses and preceptor instruction. The aim of this study was to test the effectiveness of animate course instruction in teaching laparoscopic ventral hernia repair (LVHR), its success in relationship to the course participants' previous minimally invasive surgery experience, and the role of preceptors in adapting these techniques. METHODS: Surgeons participating in a one-day LVHR course (lectures/animal laboratory) at the Carolinas Medical Center were surveyed concerning professional demographics, prior laparoscopic experience, and their performance of LVHR before and after the encounter. Standard statistics were used to determine significance (P<0.05). RESULTS: Of the 234 surgeons attending a LVHR course between 1999 and 2004, 171 (73%) answered the survey. Mean follow-up after the course was 427 days (range: 34-1202 d). Mean age was 45.9 years (range: 28-67 y). Mean time since residency was 14.4 years (range: 0.5-37 y), and 106 (62%) had learned at least basic laparoscopy in residency. One hundred twenty-six (73.7%) were in private practice. Since the course, 122 (71.3%) had performed a LVHR. They had performed a total of 2049 LVHRs (mean: 16.5; range: 1-102) compared with 1098 open herniorrhaphies (mean: 9; range: 1-23). There was no difference between those performing and not performing LVHR or the number executed with respect to practice type (P=0.67), age (P=0.47), years in practice (P=0.19), or laparoscopic experience in residency (P=0.42). Fifty-four (32%) surgeons had been precepted, and all have since performed LVHR. Surgeons with advanced laparoscopic experience were more likely to perform LVHR compared with those with only laparoscopic cholecystectomy experience (87% versus 33%, P=0.02). Indeed, of those with only laparoscopic cholecystectomy experience who performed LVHR, 80% were precepted. In the subset of surgeons who had not yet performed LVHR, 28 intended to start, 17 requested assistance, and 4 planned not to begin. CONCLUSIONS: A one-day course impacts surgeon practice patterns despite age or type of practice. Surgeons with advanced laparoscopic skills are more likely to perform LVHR. Most with limited experience will begin after working with a preceptor. Didactic instruction and a precepted experience may determine the future performance of advanced laparoscopy.

Increased plasma interleukin 6 concentrations and exaggerated adipose tissue interleukin 6 content in severely obese patients after operative trauma.

BACKGROUND: The cytokine response to operative trauma may be altered in obesity. Thus, we monitored changes in systemic and adipose tissue content of interleukin 6 (IL-6) and in insulin resistance in nonobese versus severely obese patients before and immediately after abdominal operations. METHODS: At the beginning and the end of operation, blood samples and biopsies consisting of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were collected from 13 nonobese and 33 severely obese patients. Systemic concentrations of glucose, insulin, and IL-6, as well as adipose tissue content of IL-6, were determined. RESULTS: Plasma IL-6 concentration and adipose tissue content of IL-6 increased, compared with baseline in patients after operation (plasma, 13- and 5.7-fold; VAT, 270- and 210-fold; SAT, 79- and 8.2-fold in severely obese vs nonobese patients, respectively). The increase in IL-6 in plasma and in both VAT and SAT was exaggerated in severely obese patients, compared with nonobese patients. Increases after operation in plasma IL-6 concentrations were correlated positively to the corresponding increases in both SAT and VAT IL-6 content (r = 0.57 and 0.66, respectively). Also, we found a positive correlation between the worsening of insulin resistance and increases in both plasma and SAT IL-6 concentrations (r = 0.40 and 0.51, respectively). CONCLUSIONS: Circulating IL-6 concentrations both at baseline and after operation are related strongly to abdominal adipose tissue content of content of IL-6 and are exaggerated in severely obese persons. After operation, worsening of insulin resistance is associated with increasing plasma and adipose tissue content of IL-6.

Consequences of conversion in laparoscopic colorectal surgery.

INTRODUCTION: Laparoscopic procedures converted to open approaches have been associated with higher complication rates than laparoscopic and open cholecystectomy and appendectomy. Laparoscopic colorectal resections have relatively high conversion rates compared with other laparoscopic procedures. This study was designed to evaluate outcomes of conversions compared with laparoscopic and open colorectal resections. METHODS: We reviewed 498 consecutive colorectal resections performed between 1995 and 2002. Procedures were divided into laparoscopic colorectal resections, open colorectal resections, or conversions. Demographics, underlying disease, type of procedure performed, and operative outcomes were compared between groups. RESULTS: Of the 238 laparoscopic procedures performed, 182 were completed laparoscopically and 56 (23 percent) required conversion; 260 were performed open. Conversions were associated with greater blood loss (200 (range, 50-750) vs. 100 (range, 30-900) ml), longer time to first bowel movement (82 (range, 40-504) vs. 72 (range, 12-420) hr), and longer length of stay (6 (range, 2-67) vs.. 5 (range, 2-62) days) than the laparoscopic colorectal resections group. There was no difference in operative time, transfusion requirements, intraoperative and postoperative complications, or mortality between conversions and laparoscopic colorectal resections. Conversions resulted in fewer patients requiring transfusions (4 vs. 14 percent), shorter time to first bowel movement (82 (range, 40-504) vs. 93 (range, 24-240) hr), and shorter length of stay (6 (range, 2-67) vs. 7 (range, 2-180) days) than in the open colorectal resections group. There were no differences in complications or mortality between the conversion group and the open colorectal resections group. CONCLUSIONS: Laparoscopic colorectal resections has a relatively high conversion rate; however, the converted cases have outcomes similar to open colorectal resections. In fact, the converted group required fewer blood transfusions than the open group. Experience and good judgment are fundamental for timely conversion of a laparoscopic procedure to open to decrease complication rates. Despite a high conversion rate, surgeons should consider laparoscopic colorectal resections, because even when necessary, conversion does not result in poorer outcomes than laparoscopic colorectal resections or open colorectal resections.

Components separation technique and laparoscopic approach: a review of two evolving strategies for ventral hernia repair.

When faced with large ventral hernias, surgeons frequently must choose between higher incidence of recurrence after primary repair and higher incidence of wound complications after repair with mesh. The aim of this study is to compare early outcomes between laparoscopic repair (LR) and components separation technique (CST), two evolving strategies for the management of large ventral hernias. We reviewed 42 consecutive patients who underwent CST and 45 consecutive patients who underwent LR of ventral hernia defects of at least 12 cm2. Demographics, hernia characteristics, and short-term outcomes were compared between groups. Patients in the LR group were younger (53 +/- 2 vs 68 +/- 2 years, P < 0.0001), had greater body mass index (34 +/- 2 vs 29 +/- 1 kg/m2, P = 0.02), and had larger hernia defects (318 +/- 49 vs 101 +/- 16 cm2, P < 0.0001) than patients in the CST group. The LR resulted in shorter length of hospital stay (4.9 +/- 0.9 vs 9.6 +/- 1.8 days, P < 0.0001), lower incidence of ileus (7% vs 48%, P < 0.0001), and lower incidence of wound complications (2% vs 33%, P < 0.001) than the CST. Both techniques resulted in similar operative times, transfusion requirements, and mortality. Recurrences occurred in 7 per cent of patients at mean follow-up of 16 months in the CST group and 0 per cent at mean follow-up of 9 months after LR. The LR may have a short-term advantage over the CST in terms of incidence of ileus, wound complications, and hospital stay. Because of their unique advantage over traditional hernia repairs, both techniques may play a significant role in the future treatment of large ventral hernias. Adequate training will be essential for the safe and effective implementation of these techniques within the surgical community.