Predictive factors for complexity in abdominal wall hernias: a literature scope review.

INTRODUCTION: Abdominal wall hernias encompass both ventral and incisional hernias, often poorly classified regarding complexity in general. This study aims to conduct a review on the primary topics related to defining the complexity of ventral hernias. METHODS: this is a scope review conducted following the guidelines recommended by the PRISMA-ScR directive. Searches were carried out in electronic databases including PubMed, LILACS, and EMBASE, using the descriptors: Abdominal Hernia, Hernia, Ventral Hernia, Incisional Hernia, Complex, Classification, Classify, Grade, Scale, and Definition. Combinations of these terms were employed when appropriate. Inclusion criteria encompassed articles with definitions and classifications of complex hernias, as well as those utilizing these classifications to guide treatments and patient allocation. Synonyms and related topics were also considered. Articles outside the scope or lacking the themes in their title or abstract were excluded. The database search was conducted up to July 29, 2023. RESULTS: several hernia classifications were identified as useful in predicting complexity. For this study, we considered six main criteria: size and location, loss of domain, use of abdominal wall relaxation techniques, characteristics of imaging exams, status of the subcutaneous cellular tissue, and likelihood of recurrence. CONCLUSION: complex abdominal wall hernias can be defined by characteristics analyzed collectively, relating to the patients previous clinical status, size and location of the hernia defect, status of subcutaneous cellular tissue, myofascial release techniques, and other complicating factors.

Prophylactic Use of Biologic Mesh in Ileal Conduit (PUBMIC): A Randomized Clinical Trial.

PURPOSE: We assessed the effect of prophylactic biologic mesh on parastomal hernia (PSH) development in patients undergoing cystectomy and ileal conduit (IC). MATERIALS AND METHODS: This phase 3, randomized, controlled trial (NCT02439060) included 146 patients who underwent cystectomy and IC at the University of Southern California between 2015 and 2021. Follow-ups were physical exam and CT every 4 to 6 months up to 2 years. Patients were randomized 1:1 to receive FlexHD prophylactic biological mesh using sublay intraperitoneal technique vs standard IC. The primary end point was time to radiological PSH, and secondary outcomes included clinical PSH with/without surgical intervention and mesh-related complications. RESULTS: The 2 arms were similar in terms of baseline clinical features. All surgeries and mesh placements were performed without any intraoperative complications. Median operative time was 31 minutes longer in patients who received mesh, yet with no statistically significant difference (363 vs 332 minutes, P = .16). With a median follow-up of 24 months, radiological and clinical PSHs were detected in 37 (18 mesh recipients vs 19 controls) and 16 (8 subjects in both arms) patients, with a median time to radiological and clinical PSH of 8.3 and 15.5 months, respectively. No definite mesh-related adverse events were reported. Five patients (3 in the mesh and 2 in the control arm) required surgical PSH repair. Radiological PSH-free survival rates in the mesh and control groups were 74% vs 75% at 1 year and 69% vs 62% at 2 years. CONCLUSIONS: Implementation of biologic mesh at the time of IC construction is safe without significant protective effects within 2 years following surgery.

Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia.

INTRODUCTION: Prophylactic meshes in high-risk patients prevent incisional hernias, although there are still some concerns about the best layer to place them in, the type of fixation, the mesh material, the significance of the level of contamination, and surgical complications. We aimed to provide answers to these questions and information about how the implanted material behaves based on its visibility under magnetic resonance imaging (MRI). METHOD: This is a prospective multicentre observational cohort study. Preliminary results from the first 3 months are presented. We included general surgical patients who had at least two risk factors for developing an incisional hernia. Multivariate logistic regression was used. A polyvinylidene fluoride (PVDF) mesh loaded with iron particles was used in an onlay position. MRIs were performed 6 weeks after treatment. RESULTS: Between July 2016 and June 2022, 185 patients were enrolled in the study. Surgery was emergent in 30.3% of cases, contaminated in 10.7% and dirty in 11.8%. A total of 5.6% of cases had postoperative wound infections, with the requirement of stoma being the only significant risk factor (OR = 7.59, p = 0.03). The formation of a seroma at 6 weeks detected by MRI, was associated with body mass index (OR = 1.13, p = 0.02). CONCLUSIONS: The prophylactic use of onlay PVDF mesh in midline laparotomies in high-risk patients was safe and effective in the short term, regardless of the type of surgery or the level of contamination. MRI allowed us to detect asymptomatic seromas during the early process of integration. STUDY REGISTRATION:  This protocol was registered at ClinicalTrials.gov (NCT03105895).

Small bite fascial closure technique reduces incisional hernia rates in gynecologic oncology patients.

BACKGROUND: The potential for the technique of small bite fascial closure in mitigating incisional hernias in gynecologic oncology patients still needs to be investigated. OBJECTIVE: To evaluate the impact of closure of small fascial bites compared with prior standard closure on incisional hernia rates in gynecologic oncology patients. METHODS: This is a retrospective cohort study comparing patient outcomes before and after the intervention at a single institution at a comprehensive cancer center. Patients who underwent laparotomy with a vertical midline incision for a suspected or known gynecologic malignancy with a 1-year follow-up were included. The pre-intervention cohort (large bites) had 'mass' or modified running Smead-Jones closure. In contrast, the post-intervention cohort had fascial bites taken 5-8 mm laterally with no more than 5 mm travel (small bites) closure using a 2-0 polydioxanone suture.The primary outcome was the incisional hernias rate determined by imaging or clinical examination within the first year of follow-up. Patient factors and peri-operative variates of interest were investigated for their association with hernia formation through univariate and multivariate analyses. These included age, body mass index (BMI), smoking history, estimated blood loss, pre-operative albumin, American Society of Anesthesia (ASA) physical status classification, or treatment with chemotherapy post-operatively. RESULTS: Of the 255 patients included, the total hernia rate was 12.5% (32/255 patients). Patient characteristics were similar in both cohorts. Small bite closure led to a significant reduction in hernia rates from 17.2% (22/128 patients) to 7.9% (10/127 patients), p=0.025. According to logistic regression modeling, small bite closure (OR=0.40, 95% CI 0.17 to 0.94, p=0.036) was independently associated with lower odds of hernia formation. Other factors associated with increased hernia rates were chemotherapy (OR=3.22, 95% CI 1.22 to 8.51, p=0.019) and obesity (OR=23.4, 95% CI 3.09 to 177, p=0.002). In obese patients, small bite closures led to maximal hernia rate reduction compared with large bites. CONCLUSIONS: The small bite closure technique effectively reduces hernia rates in gynecologic oncology patients undergoing midline laparotomy.

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

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

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.

Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields.

INTRODUCTION: The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh. MATERIALS METHODS: Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed. RESULTS: Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m2, and a defect size of 356.9 ± 227.7 cm2. Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications. CONCLUSIONS: Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.

Clinical outcomes and costs of retromuscular and intraperitoneal onlay mesh techniques in robotic incisional hernia repair.

BACKGROUND: This study aims to compare clinical outcomes and financial cost of intraperitoneal onlay mesh (IPOM) versus retromuscular (RM) repairs in robotic incisional hernia repairs (rIHR). METHODS: Patients who underwent either IPOM or RM elective rIHR from 2012 to 2022 were included. Demographics, operative details, postoperative outcomes, and hospital costs were directly compared. RESULTS: Sixty-nine IPOM and 55 RM were included. Age and body mass index (BMI) did not differ between both groups (IPOM vs RM: 59.3 ± 11.2 years vs. 57.5 ± 14 years, p = 0.423; BMI 34.1 ± 6.3 vs. BMI 33.2 ± 6.9, p = 0.435, respectively). Comorbidities and hernia characteristics were comparable. Extensive lysis of adhesions (> 30 min) was required more often in IPOM (18 vs. 6 in RM, p = 0.034). Defect closure was achieved in 100% of RM vs. 81.2% in IPOM (p < 0.001). Median (interquartile range) postoperative pain score was higher in RM than in IPOM [5(3-7) vs. 4(3-5), respectively, p = 0.006]. Median length of stay (0 day) and same-day discharge rate did not differ between groups (p = 0.598, p = 0.669, respectively). Six (8.7%) patients in the IPOM group versus one (1.8%) patient in the RM group were readmitted to hospital within 30 days postoperatively (p = 0.099). Perioperative complications were higher in IPOM (p = 0.011; 34.8% vs. 14.5% in RM) with higher Comprehensive Complication Index® morbidity scores [0(0-12.2) vs 0(0-0) in RM, p = 0.008)], Clavien-Dindo grade-II complications (8 vs 0 in RM, p = 0.009), and surgical site events (17 vs. 5 in RM, p = 0.024). Within a follow-up period of 57(± 28) months, recurrence rates were similar between both groups. Hospital costs did not differ between groups [IPOM: $9978 (7031-12,926) vs. RM: $8961(6701-11,222), p = 0.300]. Although postoperative complication costs were higher in IPOM ($2436 vs RM: $161, p = 0.020), total costs were comparable [IPOM: $12,415(8700-16,130) vs. RM: $9123(6789-11,457), p = 0.080]. CONCLUSION: Despite retromuscular repairs having lower postoperative complications than intraperitoneal onlay mesh repairs, both techniques offered encouraging results in robotic incisional hernia repair at a comparable total cost.

[Da Vinci robotic complex in hernia repair surgery]. / Ispol'zovanie roboticheskogo kompleksa Da Vinci v khirurgii gryzh. Opyt kliniki.

OBJECTIVE: To review the first robotic hernia repairs performed at the Ilyinsky Hospital, evolution of this technology, learning curve and early outcomes. MATERIAL AND METHODS: There were 17 procedures at the Ilyinskaya Hospital between 2021 and 2023 (13 men and 4 women). Mean age was 60 years, body mass index 28 kg/m2. ASA grade 1 was observed in 1 patient, grade 2 - 14 ones, grade 3 - 2 patients. Ventral, inguinal and umbilical hernias were diagnosed in 7, 8 and 2 cases, respectively. Ventral hernias required IPOM+ procedure in 3 cases, eTEP-RS procedure in 2 cases and eTEP-RS-TAR procedure in 2 cases. Patients with inguinal hernia underwent transabdominal preperitoneal hernia repair. In case of umbilical hernia, TARUP procedure was performed in 1 case and vTAPP procedure in 1 case. RESULTS: Mean surgery time was 2 hours 38 min (min 1 hour 35 min, max 10 hours 11 min). There was one intraoperative complication (bleeding from epigastric artery). The follow-up period ranged from 3 months to 3 years. There were no recurrent hernias. Postoperative complications were noted in 2 cases. One patient was diagnosed with epididymitis after TAPP, 1 patient - with seroma after eTEP-RS procedure. All complications were relieved by conservative treatment. Bleeding from a. epigastrica inferior was diagnosed after removal of the trocar at the end of surgery. This event required suturing. CONCLUSION: Robotic hernia repair appears to be technically feasible and safe. This approach provides favorable results regarding quality of life and recurrence rate.

Small bites versus large bites during fascial closure of midline laparotomies: a systematic review and meta-analysis.

PURPOSE: Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing up to 60% at 3-5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH. METHODS: We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%. RESULTS: 1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39-0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53-0.86; P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min; 95% CI 3.21-6.35; P < 0.001). No differences were seen regarding fascial dehiscence. CONCLUSION: SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

Initial experience with enhanced recovery after surgery (ERAS) and early discharge protocols after robotic extended totally extraperitoneal (eTEP) hernia surgery.

BACKGROUND: Though robotic adoption for eTEP surgery has decreased technical barriers to minimally invasive repairs of large ventral hernias, relatively few studies have examined outcomes of robotic-specific eTEP surgery. This study evaluates safety, feasibility, and early outcomes of ERAS/same-day discharge protocols for robotic eTEP ventral hernia repairs. METHODS: A retrospective chart review was performed for all robotic eTEP hernia surgeries at a single institution between 2019 and 2022. Analysis included patient demographics, hernia characteristics, intraoperative data, and post-operative outcomes at 30 days. ERAS protocol included: judicious use of urinary catheters with removal at end of case if placed, bilateral transversus abdominus plane (TAP) blocks, post-operative abdominal wall binder, and opioid-sparing perioperative analgesia. Patients were discharged same day from post-anesthesia care unit (PACU) if they lacked comorbidities requiring observation post-anesthesia and demonstrated stable vital signs, adequate pain control, ability to void, and ability to ambulate. Hospital length of stay (LOS) was considered 0 for same-day PACU discharges or hospitalizations < 24 h. RESULTS: 102 patients were included in this case series. 69% (70/102) of patients were discharged same-day (mean LOS 0.47 ± 0.80 days). Within 30 post-operative days, 3% (3/102) of patients presented to the ER, 2% (2/102) were readmitted to the hospital, and 1% (1/102) required reoperation. There was 1 serious complication (Clavien-Dindo grade 3/4) with an aggregate complication rate of 7.8%. CONCLUSIONS: Our initial experience with ERAS protocols and same-day discharges after robotic eTEP repair demonstrates this approach is safe and feasible with acceptable short-term patient outcomes. Compared to traditional open surgery for large ventral hernias, robotic eTEP may enable significant reductions in hospital LOS as adoption increases.

eTEP Rives-Stoppa impact on abdominal contour: a retrospective observational and clinical quality improvement study using Ellipse 9 tool.

BACKGROUND: The eTEP Rives-Stoppa (RS) procedure, increasingly used for ventral hernia repair, has raised concerns about postoperative upper abdominal bulging. This study aims to objectively evaluate changes in the abdominal contour after eTEP RS and explore potential causes using a novel analytical tool, the Ellipse 9. METHODS: Thirty patients undergoing eTEP RS without posterior rectus sheath closure were assessed before and 3 months after surgery using CT scan images. Key measurements analyzed included the distance between linea semilunaris (X2), eccentricity over the Cord (c/a Cord), superior eccentricity (c/a Sup), Y2, and the superior perimeter of the abdomen. The Ellipse 9 tool, which provides graphical images and numerical representations, was utilized alongside patient-reported outcomes to assess perceived abdominal changes. RESULTS: The study group exhibited a trend toward a flatter abdomen with reduced distance between linea semilunaris(X2). However, 17% of patients developed upper abdominal bulging (5). Significant differences in c/a Cord, c/a Sup, Y2, and the superior perimeter of the abdomen, confirmed with Bonferroni corrections, were noted between bulging (5 patients) and non-bulging groups (25 patients). There was a notable disparity between patient perceptions and objective outcomes. CONCLUSION: The eTEP RS procedure improved abdominal contour in most patients from a selected cohort. The Ellipse 9 tool was valuable for the objective analysis of these changes. The cause of bulging post-eTEP RS is probably multifactorial. Notably, there was often a discrepancy between patient perceptions of bulging and objective clinical findings.

Evaluation of Induction Immunosuppression and Risk of Incisional Hernia After Liver Transplantation.

INTRODUCTION: Liver transplantation (LT) is a technically complex operation and usually performed on ill patients. A major postoperative morbidity is incisional hernia, occurring in 9.5%-32.4% of cases. There are mixed results in transplant studies regarding potential risk factors. Additionally, the literature is lacking in the relationship between specific immunosuppressive induction agents administered during LT and postoperative incisional hernia. METHODS: A single center, retrospective cohort study of patients who underwent primary LT between 4/2011-1/2018 was conducted. Clinical variables including demographics and comorbidities were reviewed. The primary end point was the development of an incisional hernia following LT. Sub analysis was performed for secondary end points to determine potential risk factors, including immunosuppressive induction agent. RESULTS: Overall, 418 patients met inclusion criteria. At 5 y post-LT, there were 66/271 (24.4%) and 53/147 (36.1%) patients diagnosed with an incisional hernia in the methylprednisolone and basiliximab groups, respectively. After propensity score matching, there was no difference in incisional hernia development between induction agents, P = 0.19. For patients with body mass index ≥30 and postoperative seroma of the abdominal wall, the hazard ratios were 2.67 (95% CI = 1.7, 4.3) and 2.03 (95% CI = 1.1, 3.9), respectively. CONCLUSIONS: Incisional hernia rate after LT was 28.5% at 5 y. Our analysis found that immunosuppressive induction agent at LT was not associated with the development of postoperative incisional hernia. However, preoperative obesity (body mass index ≥30) and postoperative seroma of the abdominal wall were potential risk factors. Further studies are needed to delineate if these risk factors remain across institutions and in alternative settings.

Purse-string skin closure versus linear skin closure in people undergoing stoma reversal.

BACKGROUND: Stoma reversal is associated with a relatively high risk of surgical site infection (SSI), occurring in up to 40% of cases. This may be explained by the presence of microorganisms around the stoma site, and possible contamination with the intestinal contents during the open-end manipulation of the bowel, making the stoma closure site a clean-contaminated wound. The conventional technique for stoma reversal is linear skin closure (LSC). The purse-string skin closure (PSSC) technique (circumferential skin approximation) creates a small opening in the centre of the wound, enabling free drainage of contaminants and serous fluid. This could decrease the risk of SSI compared with LSC. OBJECTIVES: To assess the effects of purse-string skin closure compared with linear skin closure in people undergoing stoma reversal. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, two other databases, and three trials registers on 21 December 2022. We also checked references, searched for citations, and contacted study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing PSSC and LSC techniques in people undergoing closure of stoma (loop ileostomy, end ileostomy, loop colostomy, or end colostomy) created for any indication. DATA COLLECTION AND ANALYSIS: Two review authors independently selected eligible studies, extracted data, evaluated the methodological quality of the included studies, and conducted the analyses. The most clinically relevant outcomes were SSI, participant satisfaction, incisional hernia, and operative time. We calculated odds ratios (ORs) for dichotomous data and mean differences (MDs) for continuous data, each with its corresponding 95% confidence interval (CI). We used the GRADE approach to rate the certainty of the evidence. MAIN RESULTS: Nine RCTs involving 757 participants were eligible for inclusion. Eight studies recruited only adults (aged 18 years and older), and one study included people aged 12 years and older. The participants underwent elective reversal of either ileostomy (82%) or colostomy (18%). We considered all studies at high risk of performance and detection bias (lack of blinding) and four studies at unclear risk of selection bias related to random sequence generation. PSSC compared with LSC likely reduces the risk of SSI (OR 0.17, 95% CI 0.09 to 0.29; I2 = 0%; 9 studies, 757 participants; moderate-certainty evidence). The anticipated absolute risk of SSI is 52 per 1000 people who have PSSC and 243 per 1000 people who have LSC. The likelihood of being very satisfied or satisfied with stoma closure may be higher amongst people who have PSSC compared with people who have LSC (100% vs 89%; OR 20.11, 95% CI 1.09 to 369.88; 2 studies, 122 participants; low-certainty evidence). The results of the analysis suggest that PSSC compared with LSC may have little or no effect on the risk of incisional hernia (OR 0.51, 95% CI 0.07 to 3.70; I2 = 49%; 4 studies, 297 participants; very low-certainty evidence) and operative time (MD -2.67 minutes, 95% CI -8.56 to 3.22; I2 = 65%; 6 studies, 460 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: PSSC compared with LSC likely reduces the risk of SSI in people undergoing reversal of stoma. People who have PSSC may be more satisfied with the result compared with people who have LSC. There may be little or no difference between the skin closure techniques in terms of incisional hernia and operative time, though the evidence for these two outcomes is very uncertain.

L3W3 Incisional Hernia with LOD - Robotic eTEP-TAR Repair (with video).

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.mp4" type="video/mp4" Your browser does not support the video tag. /video Introduction: The Rives-Stoppa procedure has emerged as the preferred method for ventral hernia repair, and the principles of this technique are similarly applied in minimally invasive surgery using the eTEP (enhanced view totally extraperitoneal) approach. It appears that the eTEP approach offers excellent outcomes in terms of less post-operative pain, faster recovery, and shorter hospital stays for patients undergoing abdominal wall reconstruction (AWR). It's important to note that there are some contra-indications of this procedure. In general, laparoscopic eTEP may not be suitable for cases with large hernias and loss of domain where the working space is limited. In such cases, alternative approaches, such as using a robotic platform, may be considered to ensure an adequate working space for abdominal wall reconstruction (AWR). A robotic platform can create a working space by using the robotic arms as a "laparo-lift," enabling the AWR to be performed. Case Report: In this case, we have a 65-year-old female patient with a BMI of 28.5 who presents with a large incisional hernia with LOD. This hernia is located on the right flank and occurred after a Jalaguier incision. The CT scan provided valuable information regarding the size of the hernia, the remaining volume of the abdominal cavity, and the content of the hernia sac. Based on these radiological details, the LOD diagnosis was confirmed using the Sabbagh equation, which revealed that the hernia volume accounted for 46.47% of the total peritoneal volume. Based on the location, size of the defect, and the EHS classification for incisional hernias, the diagnosis for this case is a Complex incisional hernia of L3 right W3 with LOD. The protocol for optimization in this case involves chemo-relaxation, which refers to the injection of botulinum toxin A (BTA) into the large lateral muscles of the abdomen. This is done approximately 6 weeks before the surgery. Based on the successful reduction of the hernia during the consultation, the decision has been made to perform the Abdominal Wall Reconstruction (AWR) procedure using the robotic eTEP-TAR technique. Conclusion: The post-operative course was favorable, with the patient experiencing early active mobilization, reduced pain, and early return of bowel movement. The patient was discharged the day after the surgery.

Laparoscopic intraperitoneal onlay mesh (IPOM) with fascial repair (IPOM-plus) for ventral and incisional hernia: a systematic review and meta-analysis.

PURPOSE: Despite advancements in laparoscopic ventral hernia repair (LVHR) using the intraperitoneal onlay mesh technique (sIPOM), recurrence remains a common postoperative complication. The objective of this systematic review and meta-analysis is to compare the efficacy of defect closure (IPOM-plus) versus non-closure in ventral and incisional hernia repair. The aim is to determine which technique yields better outcomes in terms of reducing recurrence and complication rates. METHODS: A comprehensive literature review was conducted in the PubMed, Web of Science, Cochrane Library, Embase, and ClinicalTrials.gov databases from their inception until October 1, 2022, to identify all online English publications that compared the outcomes of laparoscopic ventral hernia repair with and without fascia closure. RESULTS: Three randomized controlled trials (RCTs) and eleven cohort studies involving 1585 patients met the inclusion criteria. The IPOM-plus technique was found to reduce the recurrence of hernias (OR = 0.51, 95% CI [0.35, 0.76], p < 0.01), seroma (OR = 0.48, 95% CI [0.32, 0.71], p < 0.01), and mesh bulging (OR = 0.08, 95% CI [0.01, 0.42], p < 0.01). Subgroup analysis revealed that body mass index (BMI) (OR = 0.43, 95% CI [0.29, 0.65], p < 0.0001), type of article (OR = 0.51, 95% CI [0.35, 0.76], p = 0.0008 < 0.01), geographical location (OR = 0.54, 95% CI [0.36, 0.82], p = 0.004 < 0.01), follow-up time (OR = 0.50, 95% CI [0.34, 0.73], p = 0.0004 < 0.01) had a significant influence on the postoperative recurrence of the IPOM-plus technique. CONCLUSION: The IPOM-plus technique has been shown to greatly reduce the occurrence of recurrence, seroma, and mesh bulging. Overall, the IPOM-plus technique is considered a safe and effective procedure. However, additional randomized controlled studies with extended follow-up periods are necessary to further evaluate the IPOM-plus technique.

Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias.

INTRODUCTION: Intraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs. METHODS AND PROCEDURES: Adult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively. RESULTS: A total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8-5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up. CONCLUSION: Intraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.