Descriptive Anatomy of the Porcine Ventral Abdominal Wall as a Basis for Training Ventral Hernia Repair Techniques.

Background: In recent times there has been a surge in innovative techniques concerning complex abdominal wall surgery. The availability of simulation models for comprehensive training and skill set development remains limited. Methods: Cadaveric dissections of the porcine abdominal wall were conducted to assess the suitability of anesthetized porcine models for training in both minimally invasive and open surgical procedures. Results: The panniculus carnosus, a typical muscular layer in mammals, is the outermost layer covering the anterolateral abdominal wall. Beneath it, there are four main pairs of abdominal wall muscles, mirroring the human anatomy. The rectus abdominis muscle runs straight along the linea alba and is surrounded by the rectus sheath, which is formed by the fusion of the lateral abdominal wall muscles and differs along the different regions of abdominal wall. The orientation of the muscle fibers in the lateral abdominal wall muscles, i.e., musculus obliquus externus, internus and transversus, is comparable to human anatomy. Although the transition lines between their muscular and aponeurotic part differ to some extent. Relevant for the adoption of surgical techniques, the transversus abdominis muscle is well-developed and resembles a bell curve shape as it transitions from its muscular to aponeurotic part. Conclusion: Despite minor differences in abdominal wall anatomy between pigs and humans, the porcine model provides a high level of fidelity in terms of both anatomical features and the development of skill sets relevant to hernia surgery.

Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA).

INTRODUCTION: Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement. METHODS AND ANALYSIS: We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors. ETHICS AND DISSEMINATION: No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online. PROSPERO REGISTRATION NUMBER: CRD42022347881.

Are abbreviations and acronyms to describe hernia repair techniques overused and helpful? A proposal for rationalisation.

Surgeons use abbreviations and acronyms frequently to describe surgical techniques. Recent advances and innovations in repair of abdominal wall hernias, have given rise to a plenitude of novel acronyms. For each small deviation of an existing technique authors have proposed a novel acronym. Since an acronym is most of times not self-explaining it is often hard to understand literature, lectures, symposia programs and discussions in social media. Regularly, we discover different acronyms used for the same procedure and sometimes the same or similar acronyms are used for different techniques. A clear and non-ambivalent description of surgical techniques in the literature is most valuable to summarize scientific evidence in systematic reviews and meta-analyses. We would like to propose a more rational use of abbreviations to describe hernia repair techniques based on the type of access, type of hernia, mesh position, type of mesh used and type of mesh fixation.

Prospective cohort study on mesh shrinkage measured with MRI after robot-assisted minimal invasive retrorectus ventral hernia repair using an iron-oxide-loaded polyvinylidene fluoride mesh.

BACKGROUND: Mesh-reinforced ventral hernia repair is considered the gold standard treatment for all but the smallest of hernias. Human data on mesh shrinkage in the retrorectus mesh position is lacking. A prospective observational cohort study was performed to measure mesh shrinkage in robot-assisted minimal invasive retrorectus repair of ventral hernias. METHODS: A cohort of 20 patients underwent a robot-assisted minimal invasive retrorectus repair of their ventral hernia. Magnetic resonance imaging (MRI) imaging was performed one month and thirteen months after implantation of an iron-oxide-impregnated polyvinylidene fluoride (PVDF) mesh to assess the decrease in mesh surface area. Inter-rater reliability among three radiologists regarding measurement of the mesh dimensions was analyzed. Quality of Life scoring was evaluated. RESULTS: The inter-rater reliability between the radiologists reported as the intra-class correlations proved to be excellent for mesh width (ICC 0.95), length (ICC 0.98) and surface area (ICC 0.99). Between MRI measurements at one month and thirteen months postoperatively, there was a significant increase in mesh surface area (+ 12.0 cm2, p = 0.0013) and mesh width (+ 0.8 cm, p < 0.001), while the length of the mesh remained unchanged (-0.1 cm, p = 0.754). Quality of Life Scoring showed a significant improvement in Quality of Life after one month and a further improvement at thirteen months (p < 0.001). CONCLUSION: There was an excellent inter-rater reliability between three radiologists when measuring width, length, and surface area of an iron-oxide-impregnated PVDF mesh using MRI visualization. Mesh shrinkage was not observed, instead the effective mesh surface area and width of the mesh increased.

Incidental finding of a congenital unilateral absence of the vas deferens during robotic inguinal hernia repair: missing a crucial landmark. A case report.

INTRODUCTION: We report on a case of congenital unilateral atresia of the vas deferens encountered during a robotic-assisted transabdominal preperitoneal (TAPP) inguinal hernia repair. CASE REPORT: Our 65-years-old male patient was scheduled for a bilateral robotic-assisted TAPP inguinal hernia repair because of bilateral symptomatic groin hernia. Standard intraoperative dissection obtaining a critical view of the myopectineal orifice did not allow for an identification of the vas deferens (VD) on the left side. On the right side, a normal VD was identified. There was no suspicion of an intraoperative lesion or ligation of the VD. Both gonadal and inferior epigastric vessels were present on both sides. Upon clinical evaluation, no VD was palpable in the scrotum on the left side. The diagnosis of a congenital unilateral absence of the vas deferens was made. Additional abdominal computed tomography scan revealed a congenital agenesis of the left kidney, ureter, vesicula seminalis and vas deferens. DISCUSSION: The accidental finding of a congenital absence of the vas deferens during inguinal hernia repair is rare. However, surgeons performing inguinal hernia repair should be aware of this condition and the clinical implications it poses, as this could prevent unnecessary exploration and missed diagnosis of associated underlying conditions.

History of the Creation of Self-Gripping Mesh.

Self-gripping mesh (ProgripTM, Sofradim Production, Trévoux, France) was introduced in 2006 as a synthetic prosthetic material for reinforcement of the abdominal wall in open inguinal hernia repair. As of September 2022, the self-gripping mesh has been implanted 4 million times. In June 2014 at the annual Mesh congress in Paris during an informal conversation with Dr. Chastan, Dr. Muysoms became intrigued by the history of the invention and creation of this self-gripping mesh. His fascination on this topic, was the initial bead implanted for this project to write down the history of the creation of self-gripping mesh.

EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention-With ESCP and EAES Participation.

Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.

Update Systematic Review, Meta-Analysis and GRADE Assessment of the Evidence on Parastomal Hernia Prevention-A EHS, ESCP and EAES Collaborative Project.

Objective: To perform a systematic review and meta-analysis on the effectiveness of prophylactic mesh for the prevention of parastomal hernia in end colostomy, with the ultimate objective to summarize the evidence for an interdisciplinary, European rapid guideline. Methods: We updated a previous systematic review with de novo evidence search of PubMed from inception up to June 2022. Primary outcome was quality of life (QoL). Secondary outcomes were clinical diagnosis of parastomal hernia, surgery for parastomal hernia, and 30 day or in-hospital complications Clavien-Dindo ≥3. We utilised the revised Cochrane Tool for randomised trials (RoB 2 tool) for risk of bias assessment in the included studies. Minimally important differences were set a priori through voting of the panel members. We appraised the evidence using GRADE and we developed GRADE evidence tables. Results: We included 12 randomized trials. Meta-analysis suggested no difference in QoL between prophylactic mesh and no mesh for primary stoma construction (SMD = 0.03, 95% CI [-0.14 to 0.2], I2 = 0%, low certainty of evidence). With regard to parastomal hernia, the use of prophylactic synthetic mesh resulted in a significant risk reduction of the incidence of the event, according to data from all available randomized trials, irrespective of the follow-up period (OR = 0.33, 95% CI [0.18-0.62], I2 = 74%, moderate certainty of evidence). Sensitivity analyses according to follow-up period were in line with the primary analysis. Little to no difference in surgery for parastomal hernia was encountered after pooled analysis of 10 randomised trials (OR = 0.52, 95% CI [0.25-1.09], I2 = 14%). Finally, no significant difference was found in Clavien-Dindo grade 3 and 4 adverse events after surgery with or without the use of a prophylactic mesh (OR = 0.77, 95% CI [0.45-1.30], I2 = 0%, low certainty of evidence). Conclusion: Prophylactic synthetic mesh placement at the time of permanent end colostomy construction is likely associated with a reduced risk for parastomal hernia and may confer similar risk of peri-operative major morbidity compared to no mesh placement. There may be no difference in quality of life and surgical repair of parastomal hernia with the use of either approach.

EIT Ambivium, Linea Semilunaris, and Fulcrum Abdominalis.

Building upon the recent advancements in posterior component separation techniques for complex abdominal wall hernia repair, highlights the critical importance of a thorough understanding of the abdominal wall anatomy. To address anatomical concepts with a pivotal role in hernia repair, we propose two new terminologies: "EIT Ambivium" referring to the lateral border of the rectus sheath, and "Fulcrum Abdominalis" demarcating the point where the Linea Arcuata intersects with the EIT Ambivium.

Robotic hernia surgery IV. English version : Robotic parastomal hernia repair. Video report and preliminary results.

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

EAES rapid guideline: systematic review, meta-analysis, GRADE assessment, and evidence-informed European recommendations on appendicitis in pregnancy.

BACKGROUND: Clinical practice recommendations for the management of acute appendicitis in pregnancy are lacking. OBJECTIVE: To develop an evidence-informed, trustworthy guideline on the management of appendicitis in pregnancy. We aimed to address the questions of conservative or surgical management, and laparoscopic or open surgery for acute appendicitis. METHODS: We performed a systematic review, meta-analysis, and evidence appraisal using the GRADE methodology. A European, multidisciplinary panel of surgeons, obstetricians/gynecologists, a midwife, and 3 patient representatives reached consensus through an evidence-to-decision framework and a Delphi process to formulate the recommendations. The project was developed in an online authoring and publication platform (MAGICapp). RESULTS: Research evidence was of very low certainty. We recommend operative treatment over conservative management in pregnant patients with complicated appendicitis or appendicolith on imaging studies (strong recommendation). We suggest operative treatment over conservative management in pregnant patients with uncomplicated appendicitis and no appendicolith on imaging studies (weak recommendation). We suggest laparoscopic appendectomy in patients with acute appendicitis until the 20th week of gestation, or when the fundus of the uterus is below the level of the umbilicus; and laparoscopic or open appendectomy in patients with acute appendicitis beyond the 20th week of gestation, or when the fundus of the uterus is above the level of the umbilicus, depending on the preference and expertise of the surgeon. CONCLUSION: Through a structured, evidence-informed approach, an interdisciplinary panel provides a strong recommendation to perform appendectomy for complicated appendicitis or appendicolith, and laparoscopic or open appendectomy beyond the 20th week, based on the surgeon's preference and expertise. GUIDELINE REGISTRATION NUMBER: IPGRP-2022CN210.

[Robotic hernia surgery IV. German version : Robotic parastomal hernia repair. Video report and preliminary results]. / Robotische Hernienchirurgie Teil IV : Roboterassistierte endoskopische parastomale Hernienversorgung. Videobericht und Ergebnisse.

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies.

BACKGROUND: Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. METHODS: A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. RESULTS: Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. CONCLUSION: These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

An incisional hernia results from a weakness of the abdominal wall muscles that allows fat from the inside or organs to bulge out. These hernias are quite common after abdominal surgery at the site of a previous incision. There is research that discusses different ways to close an incision and this may relate to the chance of hernia formation. The aim of this study was to review the latest research and to provide a guide for surgeons on how best to close incisions to decrease hernia rates. When possible, surgery through small incisions may decrease the risk of hernia formation. If small incisions are used, it may be better if they are placed away from areas that are already weak (such as the belly button). If the incision is larger than 1 cm, it should be closed with a deep muscle-fascia suture in addition to skin sutures. If there is a large incision in the middle of the abdomen, the muscle should be sutured using small stitches that are close together and a slowly absorbable suture should be used. For patients who are at higher risk of developing hernias, when closing the incision, the muscle layer can be strengthened by using a piece of (synthetic) mesh. There is no good research available on recovery after surgery and no clear guides on activity level or whether a binder will help prevent hernia formation.

Incidence of parastomal and incisional hernia following emergency surgery for Hinchey III-IV diverticulitis: A systematic review.

PURPOSE: The aim of this systematic review was to evaluate the risk of parastomal (PSH) and incisional hernias (IH) after emergency surgery for Hinchey III-IV diverticulitis, with comparison between the Hartmann procedure and other surgical techniques. METHODS: The Cochrane Library, Embase, PubMed (MEDLINE), Web of Science and Scopus databases were systematically searched. The primary endpoint was parastomal hernia incidence. The secondary endpoint was incisional hernia incidence. RESULTS: Five studies (four randomized controlled trials and one retrospective cohort) with a total of 699 patients were eligible for inclusion. The PSH rate was 15%-46% for Hartmann procedure, 0%-85% for primary anastomosis, 4% for resection, and 2% for laparoscopic lavage. The IH rates were 5%-38% for Hartmann procedure, 5%-27% for primary anastomosis, 9%-12% for primary resection, and 3%-11% for laparoscopic lavage. CONCLUSIONS: Both the parastomal and incisional hernia incidences are poorly evaluated and reported, and varied greatly between the studies.

Open versus robotic-assisted laparoscopic posterior component separation in complex abdominal wall repair.

BACKGROUND: Transversus abdominis release (TAR) is a surgical technique used in the treatment of complex ventral hernias. The aim of this study was to compare outcomes of open (oTAR) versus robotic-assisted (rTAR) posterior component separation by TAR. METHODS: Consecutive patients at two European hernia centres who underwent bilateral TAR were included. The primary endpoint was the duration of postoperative hospital stay. RESULTS: Data from 90 rTAR and 79 oTAR operations were evaluated. Patient demographics were similar between groups in terms of age, sex, BMI, and co-morbidities. There were more smokers, and hernias were larger in the oTAR group (width 8.7 cm versus 10.0 cm; P = 0.031, length 11.6 cm versus 14.1 cm; P = 0.005). Duration of postoperative hospital stay was significantly shorter in the rTAR group (3.4 days versus 6.9 days; P < 0.001). Short-term serious complications (Clavien-Dindo grade III and above) were more frequent (20.3 per cent versus 7.8 per cent; P = 0.018), and there were more surgical site infections (12.7 per cent versus 3.3 per cent; P = 0.010) in the oTAR group. During a median follow-up of 19 months in the rTAR group and 43 months in the oTAR group, reoperation (4.4 per cent versus 8.9 per cent; P = 0.245), and recurrence rates (5.6 per cent versus 5.1 per cent; P > 0.009) were similar. CONCLUSION: Patients with ventral incisional hernias who undergo bilateral rTAR had significantly shorter postoperative hospital stays and fewer short-term complications compared with patients undergoing bilateral oTAR.

Prevention of Incisional Hernias by Prophylactic Mesh-augmented Reinforcement of Midline Laparotomies for Abdominal Aortic Aneurysm Treatment: Five-year Follow-up of a Randomized Controlled Trial.

INTRODUCTION: The incidence of incisional hernias (IHs) after open repair of an abdominal aortic aneurysm (AAA) is high. Several randomized controlled trials have reported favorable results with the use of prophylactic mesh to prevent IHs, without increasing complications. In this analysis, we report on the results of the 60-month follow-up of the PRIMAAT trial. METHODS: In a prospective, multicenter, open-label, randomized design, patients were randomized between prophylactic retrorectus mesh reinforcement (mesh group), and primary closure of their midline laparotomy after open AAA repair (no-mesh group). This article reports on the results of clinical follow-up after 60 months. If performed, ultrasonography or computed tomography were used for the diagnosis of IHs. RESULTS: Of the 120 randomized patients, 114 were included in the intention-to-treat analysis. Thirty-three patients in the no-mesh group (33/58-56.9%) and 34 patients in the mesh group (34/56-60.7%) were evaluated after 5 years. In each treatment arm, 10 patients died between the 24-month and 60-month follow-up. The cumulative incidence of IHs in the no-mesh group was 32.9% after 24 months and 49.2% after 60 months. No IHs were diagnosed in the mesh group. In the no-mesh group, 21.7% (5/23) underwent reoperation within 5 years due to an IH. CONCLUSIONS: Prophylactic retrorectus mesh reinforcement after midline laparotomy for the treatment of AAAs safely and effectively decreases the rate of IHs. The cumulative incidence of IHs after open AAA repair, when no mesh is used, continues to increase during the first 5 years after surgery, which leads to a substantial rate of hernia repairs.