Analgesia con bloqueo TAP y bomba elastomérica en la reparación de hernias ventrales (primarias e incisionales) abdominales por laparoscopia en régimen de cirugía mayor ambulatoria / Analgesia with TAP block and elastomeric pump in the repair of ventral (primary and incisional) abdominal hernias by laparoscopy in major outpatient surgery

Antecedentes: El dolor moderado severo es una limitación para la incorporación de procedimientos en cirugía mayor ambulatoria (CMA), siendo uno de los principales motivos de reingreso o consulta a urgencias en las primeras horas del postoperatorio. Representa un indicador de calidad para las unidades de CMA. Algún estudio ya mide la eficacia de las bombas elastoméricas en el domicilio en CMA, pero no para la reparación de eventración de línea media por laparoscopia. Objetivo: Se diseñó un estudio para medir el dolor postoperatorio en la reparación de hernias ventrales, primarias o incisionales, de línea media por vía laparoscópica (malla fijada con tackers y cola de cianocrialato) con un diámetro transverso inferior a los 8 centímetros, en pacientes ASA I-II. Se valoró la viabilidad de la utilización de las bombas elastoméricas, con infusión continua de antinfl amatorio, opiáceos débiles y antieméticos en el domicilio del paciente. Pacientes y métodos: Estudio prospectivo observacional en pacientes ASA I-II, intervenidos de reparación de hernia ventral por laparoscopia, bajo una estrategia de control de dolor multimodal. Se realizó anestesia general endovenosa, con propofol y remifentanilo, junto a perfusión de lidocaína, y bloqueo TAP ecoguiado con levobupivacaína y mepivacaína con punción bilateral. Se inició la analgesia endovenosa intraoperatoriamente y para domicilio se pautó bomba elastomérica con dexketoprofeno, tramadol y ondansetrón, que se inció en la zona de recuperación postanestésica, junto a paracetamol fi jo y metamizol de rescate. La enfermería integrante de la unidad de hospitalización a domicilio se encargó del control postoperatorio en el domicilio del paciente. Se midió a las 24 h y 48 h el dolor postoperatorio a través de las escalas EVA y Andersen, además de las complicaciones que hubieran surgido (disfunción del dispositivo, náuseas/vómitos, complicaciones quirúrgicas)...(AU)

Background: Severe moderate pain is a limitation for the incorporation of procedures in major ambulatory surgery (MOS), being one of the main reasons for readmission or consultation to the emergency department in the first postoperative hours. It represents a quality indicator for AMC units. Some studies have already measured the efficacy of elastomeric pumps in the home in the AMC, but not for laparoscopic repair of midline eventration. Objective: A study was designed to measure postoperative pain in the repair of ventral, primary or incisional, midline hernias by laparoscopy (mesh fixed withtackers and cyanocryalate glue) with a transverse diameter of less than 8 centimeters, in ASA I-II patients. The feasibility of using elastomeric pumps withcontinuous infusion of anti-inflammatory drugs, weak opioids and antiemetics at the patient’s home was assessed. Patients and methods: Prospective observational study in ASA I-II patients who underwent laparoscopic ventral hernia repair under a multimodal pain control strategy. Intravenous general anesthesia was performed with propofol and remifentanil, together with lidocaine perfusion, and ultrasound-guided TAP block with levobupivacaine and mepivacaine with bilateral puncture. Intravenous analgesia was started intraoperatively and an elastomeric pump with dexketoprofen, tramadoland ondansetron was prescribed for home use, which was started in the postanesthetic recovery area, together with fixed paracetamol and rescue metamizole. The nursing staff of the home hospitalization unit was in charge of postoperative monitoring at the patient’s home. Postoperative pain was measured at 24 h and 48 h using the VAS and Andersen scales, as well as any complications that might have arisen (device dysfunction, nausea/vomiting, surgical complications). Patient satisfaction was measured by means of a survey at 30 days, during the postoperative follow-up with the surgeon.(AU)

European Hernia Society guidelines on management of rectus diastasis.

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

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

The European Hernia Society classification applied to the rare cases of parastomal hernia after ileal conduit urinary diversion: a retrospective cohort of 96 patients.

INTRODUCTION: To determine the incidence and classification of parastomal hernia (PH) following ileal conduit urinary diversion and to identify risk factors for PH development. METHODS: We performed a retrospective review of our cystectomy database which includes benign and malignant cases from 2011-2016. Patients with an abdominal CT at 24 ± 2 months post-operation were included. PH were classified according to the European Hernia Society (EHS) system. Regression analyses were performed on variables associated with parastomal hernia. RESULTS: A total of 96 patients were included in the study. The incidence of PH on CT is 20.2% at one year and 28.1% at two years. Using the EHS classification, the majority of PH was small (≤ 5 cm), but up to 50% were associated with a concomitant incisional hernia. On multivariable analysis, (C-index = 0.71), obesity was associated with a higher risk of PH (OR = 2.8, 95% CI 1.06-7.42, p = 0.04), whereas prior tobacco use was associated with a lower risk of PH at 2 years (OR = 0.23, 95% CI 0.09-0.63, p < 0.01). CONCLUSIONS: Hernia after ileal conduit is common with radiographic rates approaching 30% at two years, with obesity being an independent risk factor. The relationship between prior tobacco use and a lower hernia rate may be limited to this study but presents an opportunity for future investigation. No difference in PH rates were observed between open and minimally invasive surgery and between intracorporeal and extracorporeal conduits.

Pooled data analysis of primary ventral (PVH) and incisional hernia (IH) repair is no more acceptable: results of a systematic review and metanalysis of current literature.

PURPOSE: Primary (PVHs) and incisional (IHs) ventral hernias represent a common indication for surgery. Nevertheless, most of the papers presented in literature analyze both types of defect together, thus potentially introducing a bias in the results of interpretation. The purpose of this systematic review and meta-analysis is to highlight the differences between these two entities. METHODS: Methods MEDLINE, Scopus, and Web of Science databases were reviewed to identify studies evaluating the outcomes of both open and laparoscopic repair with mesh of PVHs vs IHs. Search was restricted to English language literature. Risk of bias was assessed with MINORS score. Primary outcome was recurrence, and secondary outcomes were baseline characteristics and intraoperative and postoperative data. Fixed effects model was used unless significant heterogeneity, assessed with the Higgins I square (I2), was encountered. RESULTS: The search resulted in 783 hits, after screening; 11 retrospective trials were selected including 38,727 patients. Mean MINORS of included trials was 15.2 (range 5-21). The estimated pooled proportion difference for recurrence was - 0.09 (- 0.11; - 0.07) between the two groups in favor of the PVH group. On metanalysis, PVHs were smaller in area and diameters, affected younger and less comorbid patients, and were more frequently singular; the operative time and length of stay was quicker. Other complications did not differ significantly. CONCLUSION: Our paper supports the hypothesis that PVH and IH are different conditions with the latter being more challenging to treat. Accordingly, EHS classifications should be adopted systematically as well as pooling data analysis should be no longer performed in clinical trials.

The endoscopic retromuscular repair of ventral hernia: the eTEP technique and early results.

PURPOSE: The aim of this article is to describe the technique and early follow-up results of abdominal wall reconstruction (AWR) by minimally invasive surgery (MIS); it concerns the already described endoscopic (retromuscular) Rives procedure (e-Rives) and posterior component separation with transversus abdominis release (TAR) by endoscopic approach (eTEP-TAR). METHOD: This is a prospective study which consists of 60 patients operated on between May 2016 and December 2017 by a single surgeon and monitored until July 2018. This is a heterogenic cohort with different hernia types (lateral, median, combined) which were also treated with different meshes. This material includes physiological and biomechanical issues related to the abdominal wall, the key stages of the operation including port placement strategy. RESULTS: The group of patients are 55% male, having a mean age of 53.3 years old, mean BMI of 29.3 and median ASA score of 1.83. The majority of the hernia types is represented by incisional hernia (61.7%) located especially on the median side of the abdomen (80%); more than half of them (60%) are reducible. There were 6 (10%) intraoperative complications that lead to four conversions to open or traditional laparoscopic techniques. Postoperative re-admission-two cases: one case with small bowel obstruction, solved by laparoscopic surgery and one case with hemorrhagic gastritis because of non-steroidal anti-inflammatory treatment that required only medical treatment. Quality of life (assessed on a 0-10 scale) evaluating the postoperative pain, normal activity and aesthetics, shows a significant improvement after 2 weeks and 3 months postoperatively compared to the preoperative level. 93.3% of the patients have been monitored and no recurrences after a mean of 15 months have been reported. CONCLUSION: A thorough understanding of the anatomy and surgical technique is mandatory. The eTEP approach is a feasible and safe option in MIS ventral hernia repair.

Prospective evaluation of poly-4-hydroxybutyrate mesh in CDC class I/high-risk ventral and incisional hernia repair: 18-month follow-up.

BACKGROUND: Long-term resorbable mesh represents a promising technology for complex ventral and incisional hernia repair (VIHR). Preclinical studies indicate that poly-4-hydroxybutyrate (P4HB) resorbable mesh supports strength restoration of the abdominal wall. This study evaluated outcomes of high-risk subjects undergoing VIHR with P4HB mesh. METHODS: This was a prospective, multi-institutional study of subjects undergoing retrorectus or onlay VIHR. Inclusion criteria were CDC Class I, defect 10-350 cm2, ≤ 3 prior repairs, and ≥ 1 high-risk criteria (obesity (BMI: 30-40 kg/m2), active smoker, COPD, diabetes, immunosuppression, coronary artery disease, chronic corticosteroid use, hypoalbuminemia, advanced age, and renal insufficiency). Physical exam and/or quality of life surveys were performed at regular intervals through 18 months (to date) with longer-term, 36-month follow-up ongoing. RESULTS: One hundred and twenty-one subjects (46M, 75F) with an age of 54.7 ± 12.0 years and BMI of 32.2 ± 4.5 kg/m2 (mean ± SD), underwent VIHR. Comorbidities included the following: obesity (n = 95, 78.5%), hypertension (n = 72, 59.5%), cardiovascular disease (n = 42, 34.7%), diabetes (n = 40, 33.1%), COPD (n = 34, 28.1%), malignancy (n = 30, 24.8%), active smoker (n = 28, 23.1%), immunosuppression (n = 10, 8.3%), chronic corticosteroid use (n = 6, 5.0%), advanced age (n = 6, 5.0%), hypoalbuminemia (n = 3, 2.5%), and renal insufficiency (n = 1, 0.8%). Hernia types included the following: primary ventral (n = 17, 14%), primary incisional (n = 54, 45%), recurrent ventral (n = 15, 12%), and recurrent incisional hernia (n = 35, 29%). Defect and mesh size were 115.7 ± 80.6 and 580.9 ± 216.1 cm2 (mean ± SD), respectively. Repair types included the following: retrorectus (n = 43, 36%), retrorectus with additional myofascial release (n = 45, 37%), onlay (n = 24, 20%), and onlay with additional myofascial release (n = 8, 7%). 95 (79%) subjects completed 18-month follow-up to date. Postoperative wound infection, seroma requiring intervention, and hernia recurrence occurred in 11 (9%), 7 (6%), and 11 (9%) subjects, respectively. CONCLUSIONS: High-risk VIHR with P4HB mesh demonstrated positive outcomes and low incidence of hernia recurrence at 18 months. Longer-term 36-month follow-up is ongoing.

Designing a ventral hernia staging system.

INTRODUCTION: The absence of a standardized classification scheme for ventral hernias hinders comparisons within the literature, indirectly delaying meaningful discussions regarding technique. We aimed to generate a comprehensive staging system that stratifies patients by risk of developing wound morbidity and hernia recurrence. METHODS: Our prospective database of all ventral hernia repairs (2006-2013) was reviewed with no exclusion based on technique or prosthetic. The presence of patient comorbidities, contamination and hernia dimensions-width/location on computed topography-was evaluated to identify variables most closely associated with surgical site occurrence (SSO) and recurrence. Predicted odds ratios and relative hazards, for SSO and recurrence, respectively, were used to partition patients into stages corresponding with increasing levels of risk. RESULTS: Hernia width (OR 2.24, HR 1.73) and the presence of contamination (OR 1.81, HR 2.04) were most significantly associated with increased risk of SSO and recurrence, while hernia location and the presence of comorbidities were not. Stage I hernias are <10 cm/clean and associated with low SSO and recurrence risk. Stage II hernias are 10-20 cm/clean or <10 cm contaminated and carry an intermediate risk of SSO and recurrence. Stage III hernias are either ≥10/contaminated or any hernia ≥20 cm, and these are associated with high SSO and recurrence risk. Stages I-III carry a concordance index of 0.67 for SSO and 0.61 for recurrence. CONCLUSION: Hernia width and wound class can be used to stratify patients into stages (I-III) with increasing risk of wound morbidity and recurrence. This can be the foundation for future inclusion and exclusion criteria.

Incisional Hernia Classification Predicts Wound Complications Two Years after Repair.

Classification of ventral hernias (VHs) into categories that impact surgical outcome is not well defined. The European Hernia Society (EHS) classification divides ventral incisional hernias by midline or lateral location. This study aimed to determine whether EHS classification is associated with wound complications after VH repair, indicated by surgical site occurrences (SSOs). A retrospective cohort study of patients who underwent VH repair at a tertiary referral center between July 1, 2005 and May 30, 2012, was performed. EHS classification, comorbidities, and operative details were determined. Primary outcome was SSO within two years, defined as an infection, wound dehiscence, seroma, or enterocutaneous fistula. There were 538 patients included, and 51.5 per cent were female, with a mean age of 54.2 ± 12.4 years and a mean body mass index of 32.4 ± 8.6 kg/m(2). Most patients had midline hernias (87.0%, n = 468). There were 47 patients (8.7%) who had a lateral hernia, and 23 patients (4.3%) whose repair included both midline and lateral components. Overall rate of SSO was 39 per cent (n = 211) within two years. The rate of SSO by VH location was: 39 per cent (n = 183) for midline, 23 per cent (n = 11) for lateral, and 74 per cent (n = 17) for VHs with midline and lateral components (P = <0.001). Patients whose midline hernia spanned more than one EHS category also had a higher rate of SSOs (P = 0.001). VHs are often described by transverse dimension alone, but a more descriptive classification system offers a richness that correlates with outcomes.

The use of an acellular porcine dermal collagen implant in the repair of complex abdominal wall defects: a European multicentre retrospective study.

BACKGROUND: The use of biological materials for the repair of complex abdominal wall defects has increased over the years; however, the role of these materials in routine practice remains unclear. The aim of the study was to evaluate clinical outcomes following the use of Permacol™ porcine collagen surgical implant in complex abdominal wall repair. METHODS: This subset analysis of seven European sites from a multicentre retrospective study included patients undergoing open or laparoscopic surgery and treated with Permacol™ surgical implant. Inguinal, parastomal, diaphragmatic, perineal, and hiatal repairs were excluded. Only patients with at least 12 months of follow-up after surgery were included. RESULTS: A total of 109 patients (56 males and 53 females) were included. Patients had a median of two comorbidities (range 0-6). Thirty-three per cent of patients were treated for recurrent hernia. All but one case used an open approach. Sixty-six per cent were Center for Disease Control wound class II-IV at the time of surgery. Fascial closure was achieved in 69%. Median follow-up length was 720 days (range 368-2857). Recurrence rates at 1 and 2 years were 9.2 and 18.3 %, respectively, and were higher in cases without fascial closure. One-year recurrence was higher following use of an onlay technique (P = 0.025). In a multivariate analysis, among 16 comorbidities examined only fascial closure significantly impacted 1-year recurrence (P = 0.049). CONCLUSIONS: Data from this large retrospective multicentre European study strongly suggest the use of Permacol™ porcine collagen surgical implant to be safe and effective for complex abdominal wall repair. The recurrence rate was impacted by fascial closure.

[The trocar hernia after laparoscopic operative interventions. classification, treatment, prophylaxis].

Own experience of treatment of patients, suffering trocar hernias, occurred after laparoscopic operative interventions, was analyzed. Classification of trocar hernias was proposed, the main factors of risk and prognostic criteria of a trocar hernias formation were analyzed. The main methods of the trocar hernias correction are adduced.

Importance of recurrence rating, morphology, hernial gap size, and risk factors in ventral and incisional hernia classification.

BACKGROUND: There is limited evidence on the natural course of ventral and incisional hernias and the results of hernia repair, what might partially be explained by the lack of an accepted classification system. The aim of the present study is to investigate the association of the criteria included in the Wuerzburg classification system of ventral and incisional hernias with postoperative complications and long-term recurrence. METHODS: In a retrospective cohort study, the data on 330 consecutive patients who underwent surgery to repair ventral and incisional hernias were analyzed. The following four classification criteria were applied: (a) recurrence rating (ventral, incisional or incisional recurrent); (b) morphology (location); (c) size of the hernial gap; and (d) risk factors. The primary endpoint was the occurrence of a recurrence during follow-up. Secondary endpoints were incidence of postoperative complications. Independent association between classification criteria, type of surgical procedures and postoperative complications was calculated by multivariate logistic regression analysis and between classification criteria, type of surgical procedures and risk of long-term recurrence by Cox regression analysis. RESULTS: Follow-up lasted a mean 47.7 ± 23.53 months (median 45 months) or 3.9 ± 1.96 years. The criterion "recurrence rating" was found as predictive factor for postoperative complications in the multivariate analysis (OR 2.04; 95 % CI 1.09-3.84; incisional vs. ventral hernia). The criterion "morphology" had influence neither on the incidence of the critical event "recurrence during follow-up" nor on the incidence of postoperative complications. Hernial gap "width" predicted postoperative complications in the multivariate analysis (OR 1.98; 95 % CI 1.19-3.29; ≤5 vs. >5 cm). Length of the hernial gap was found to be an independent prognostic factor for the critical event "recurrence during follow-up" (HR 2.05; 95 % CI 1.25-3.37; ≤5 vs. >5 cm). The presence of 3 or more risk factors was a consistent predictor for "recurrence during follow-up" (HR 2.25; 95 % CI 1.28-9.92). Mesh repair was an independent protective factor for "recurrence during follow-up" compared to suture (HR 0.53; 95 % CI 0.32-0.86). CONCLUSIONS: The ventral and incisional hernia classification of Dietz et al. employs a clinically proven terminology and has an open classification structure. Hernial gap size and the number of risk factors are independent predictors for "recurrence during follow-up", whereas recurrence rating and hernial gap size correlated significantly with the incidence of postoperative complications. We propose the application of these criteria for future clinical research, as larger patient numbers will be needed to refine the results.

European Hernia Society classification of parastomal hernias.

PURPOSE: A classification of parastomal hernias (PH) is needed to compare different populations described in various trials and cohort studies, complete the previous inguinal and ventral hernia classifications of the European Hernia Society (EHS) and will be integrated into the EuraHS database (European Registry of Abdominal Wall Hernias). METHODS: Several members of the EHS board and invited experts gathered for 2 days to discuss the development of an EHS classification of PH. The discussions were based on a literature review and critical appraisal of existing classifications. RESULTS: The classification proposal is based on the PH defect size (small is ≤5 cm) and the presence of a concomitant incisional hernia (cIH). Four types were defined: Type I, small PH without cIH; Type II, small PH with cIH; Type III, large PH without cIH; and Type IV, large PH with cIH. In addition, the classification grid includes details about whether the hernia recurs after a previous PH repair or whether it is a primary PH. Clinical validation is needed in the future to assess if the classification allows us to differentiate the treatment strategy and if the classification impacts outcome in these different subgroups. CONCLUSION: A classification of PH divided into subgroups according to size and cIH was formulated with the aim of improving the ability to compare different studies and their results.

Totally laparoscopic abdominal wall reconstruction: lessons learned and results of a short-term follow-up.

PURPOSE: Totally Laparoscopic Abdominal Wall Reconstruction (TLAWR) combines the laparoscopic component separation and the laparoscopic ventral hernia repair, with the purpose of further increasing the benefits of a minimally invasive procedure. However, neither the patient selection criteria nor the long-term results of this technique have been reported. Our objective is to discuss our experience with five patients who received a TLAWR. METHODS: All patients with a midline incisional hernia who underwent a TLAWR from September 2008 to October 2009 were retrospectively reviewed for early and late postoperative complications. RESULTS: A total of five patients underwent the procedure, with a mean age of 48.6 ± 7.9 years. The mean length of stay was 9.2 ± 5.4 days, and follow-up was 12.3 ± 6.8 months. The mean defect size was 175.8 ± 56.2 cm(2). There were no early or late wound complications. Two patients had an early respiratory complication, and one patient developed a port site hernia and small bowel obstruction early after procedure, which required a re-operation. Three patients (60 %) experienced a recurrence. Possible risk factors for recurrence include previous failed hernia repair, loss of domain, large hernias and close proximity to bony structures. CONCLUSIONS: Although TLAWR is feasible and improves wound complications, it may be associated with higher recurrence. Appropriate patient selection is imperative in order for the patient to benefit from this technique.

Single-access laparoscopic primary and incisional prosthetic hernia repair: first 50 patients.

BACKGROUND: Primary and incisional hernia can be repaired by multitrocar laparoscopy. Single-access laparoscopy (SAL) recently gained interest to decrease the invasiveness and to reduce the abdominal trauma, besides improved cosmetic results. The authors report first 50 patients who consulted for primary and incisional hernia and treated by SAL prosthetic repair. PATIENTS AND METHODS: Between December 2009 and March 2012, 50 patients (24 females, 26 males) were submitted to SAL for primary (23) and incisional hernia (27). Mean age was 49.1 ± 15.1 years (17-75), and mean body mass index 29.7 ± 5.7 kg/m(2) (19-44.1). A total of 26 primary and 30 incisional hernias were treated. The technique consisted in implied the use of an 11-mm trocar for 10-mm scope, curved reusable instruments without trocars, and dualface prosthesis fixed by tacks without transfascial closures. RESULTS: No conversion to open surgery nor addition of one or more trocars was necessary. Mean perioperative hernia sizes were 7.0 ± 5.0 cm (2-24) in length and 6.0 ± 3.4 cm (1-16) in width, for a surface of 55.0 ± 64.6 cm(2) (2.8-268.2). Mean prosthesis size used was 188.1 ± 113.4 cm(2) (56.2-505.6). Mean laparoscopic time was 60.2 ± 32.8 min (26-153), and mean final scar length was 21.2 ± 4.5 mm (13-35). Mean hospital stay was 2.2 ± 1.2 days (1-8). Perioperative complications were registered in 4 patients and minor early complications in 13 patients of each group. After a mean follow-up of 16.1 ± 8.8 months (4-34), 2 late complications were observed in one patient of each group. CONCLUSION: Primary and incisional hernia can safely be treated by SAL prosthetic repair, but a learning curve is unavoidable. Thanks to this approach, in patients with primary hernia, only a small scar is finally visible, and in patients who proved to be prone to develop incisional hernia, the number of fascial incisions can be reduced.

EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair.

BACKGROUND: Although the repair of ventral abdominal wall hernias is one of the most commonly performed operations, many aspects of their treatment are still under debate or poorly studied. In addition, there is a lack of good definitions and classifications that make the evaluation of studies and meta-analyses in this field of surgery difficult. MATERIALS AND METHODS: Under the auspices of the board of the European Hernia Society and following the previously published classifications on inguinal and on ventral hernias, a working group was formed to create an online platform for registration and outcome measurement of operations for ventral abdominal wall hernias. Development of such a registry involved reaching agreement about clear definitions and classifications on patient variables, surgical procedures and mesh materials used, as well as outcome parameters. The EuraHS working group (European registry for abdominal wall hernias) comprised of a multinational European expert panel with specific interest in abdominal wall hernias. Over five working group meetings, consensus was reached on definitions for the data to be recorded in the registry. RESULTS: A set of well-described definitions was made. The previously reported EHS classifications of hernias will be used. Risk factors for recurrences and co-morbidities of patients were listed. A new severity of comorbidity score was defined. Post-operative complications were classified according to existing classifications as described for other fields of surgery. A new 3-dimensional numerical quality-of-life score, EuraHS-QoL score, was defined. An online platform is created based on the definitions and classifications, which can be used by individual surgeons, surgical teams or for multicentre studies. A EuraHS website is constructed with easy access to all the definitions, classifications and results from the database. CONCLUSION: An online platform for registration and outcome measurement of abdominal wall hernia repairs with clear definitions and classifications is offered to the surgical community. It is hoped that this registry could lead to better evidence-based guidelines for treatment of abdominal wall hernias based on hernia variables, patient variables, available hernia repair materials and techniques.

A new classification of parastomal hernias--from the experience at Bielanski Hospital in Warsaw.

UNLABELLED: Parastomal hernia is the most common local stoma complication. The incidence of parastomal hernia reaches 48%, and in a certain proportion of patients it is considered to be an inevitable consequence of stoma formation. The current classifications of parastomal hernias (Rubin, Devlin) are of little clinical value, which is supported by the fact that they have not been used in any publication presenting surgical treatment results in parastomal hernia. Moreover, these classifications do not include recommendations regarding surgical approach selection in those cases where surgical treatment is indicated. These disadvantages clearly indicate a need for developing a new classification of a greater practical value. THE AIM OF THE STUDY: was to present a suggested new parastomal hernia classification, based on structural criteria, and its use in surgical approach selection. MATERIAL AND METHODS: The authors presented a group of 52 patients registered in Outpatient Stoma Clinic at Bielanski Hospital in Warsaw, who had been diagnosed with parastomal hernia, defined as a type of hernia associated with postoperative artificial external intestinal fistula, who also had indications for surgical treatment of this stomal complication. These patients underwent a reconstructive procedure of their parastomal hernia with a surgical technique involving the placement of a monofilament polypropylene mesh in the preperitoneal space and repair of co-existing stomal complications using the variants of surgical techniques adequate for a given parastomal hernia type. Based on our studies and clinical experience, we propose a new classification of parastomal hernias, based on structural criteria. All hernias were divided into four groups (type I-IV) depending on hernia size and the presence of hernia in the postoperative scar. Qualification of a given hernia to a specific type was achieved based on physical examination, which makes the suggested classification a simple tool, useful in everyday practice. Each parastomal hernia type requires selecting a suitable surgical approach. RESULTS: In the study group, 44 patients were diagnosed with primary hernia, and 8 - with recurrent hernia. In one case of recurrent hernia it was another recurrence. There were 11 type I hernias, 7 type II hernias, 24 type III hernias, and 4 type IV hernias in the study group. No statistically significant relationship between the type of hernia and the sex of the patients was observed for p = 0.05. However, there was a significant difference between the BMI values and individual hernia types. Patients with type I hernia had the lowest mean BMI value and patients with type IV hernia had the highest mean BMI value. The mean duration of postoperative follow-up was 58 months. There were 5 cases (9.6%) of parastomal hernia recurrence in the study group. A statistical analysis of the results showed that parastomal hernia types identified based on structural criteria differ from one another in parameters such as BMI, indications for surgery, or recurrence rates. CONCLUSIONS: The new classification of parastomal hernias is a simple way of identifying patients who require a different therapeutic approach. Thus, it has a practical application as it helps to select a suitable surgical technique. It may be also used for identification of homogeneous groups of patients and therefore allows for a reliable and objective comparison of treatment outcomes.

[The role of surgical access in postoperative ventral hernia development].

Long-term follow-up of 508 patients after various surgical procedures has been conducted. Of the 351 patients were operated on using a paramedian incision, 109 had an upper median laparotomy and the rest 48 had an oblique subcostal incision. Post-operative ventral hernias were registered in 45 (8.86%) patients. The upper median laparotomy herniated in 18 (16.51%) patients, paramedian incision - in 17 (4.84%), and the oblique subcostal incision herniated in 10 (20.83%). Hernia was noticed by the patient within 12 months after the initial operation in 46.67%, of them in 85.71% - within first 6 months. 53,33% of patients were diagnosed with postoperative hernia only after thorough examination. Thus, paramedian incision is considered to be the most preferable access. Postoperative hernias develop within the first 6-12 months postoperatively, later hernia registration is a result of poor examination.