Abdominal Wall Reinforcement Research Articles

Abdominal Wall Reinforcement Using Acellular Tissue Matrix after Deep Inferior Epigastric Perforator Flap Harvest for Breast Reconstruction

Abdominal Wall Reinforcement Using Acellular Tissue Matrix after Deep Inferior Epigastric Perforator Flap Harvest for Breast Reconstruction

Surgical Outcomes of Vertical Rectus Abdominis Myocutaneous Flap Pelvic Reconstruction.

The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. We aimed to evaluate outcomes of VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction. We conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January 2001 and March 2021. Our primary outcome measure included recipient and donor surgical site occurrences (SSOs). We identified a total of 546 patients (55% females) with a mean age was 58 years and mean BMI was 27 kg/m 2. Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient-site SSOs occurred in 38% of patients while donor-site SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients while bulge developed in 6.4% of patients. Cox proportional hazards regression model for hernia occurrence identified age, BMI, tobacco use (HR 2.03, 95% CI [1.02 - 4.04]) and use as an extended VRAM (HR 2.13, 95% CI [1.04 - 4.36]). The use of mesh or component separation were not independent protective factors for hernia occurrence. The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor site hernia occurrence.

T-Line mesh as a safe and effective option for abdominal wall reinforcement with autologous breast reconstruction

T-Line mesh as a safe and effective option for abdominal wall reinforcement with autologous breast reconstruction

Similar collagen distribution in full-thickness skin grafts in intraperitoneal and onlay positions, an experimental mice-study

PurposeAutologous full-thickness skin grafting (FTSG) has the potential to become an option in abdominal wall repair. An understanding of tissue remodelling in the extracellular matrix (ECM) is crucial as this interplay determines such parameters as tissue strength and flexibility. This cross-sectional preclinical laboratory study in mice provides information on the distribution of collagen types and matrix metalloproteinases (MMPs) in the ECM of FTSGs in the intraperitoneal and onlay positions compared with internal controls. The aim was to evaluate morphologic changes after tissue remodelling and repair in FTSGs applied in the two positions and to detect any adverse host response.MethodsECM components were evaluated as follows: qualitative examination of collagen bundle thickness using Picrosirius Red staining (collagen types I, III and IV); and evaluation of collagen types IV and V, as well as MMPs 1, 8 and 9 using immunohistochemical staining. Full-thickness grafts transplanted between female twin mice were examined as this best mimics autologous transplantation.ResultsAt 8 weeks, FTSGs in the intraperitoneal position did not show any noticeable differences in morphologic appearance to those in the onlay position. Both intraperitoneal and onlay FTSGs showed increases in the amount of thick collagen bundles compared to internal controls. No correlation was seen between distribution of MMPs 1, 8 or 9 and distribution of collagen types I, III, IV or V.ConclusionThis preclinical study shows that FTSGs in both intraperitoneal and onlay positions are possible application site options and, by extension, promising application site options for abdominal wall reinforcement in hernia surgery. Clinical studies in humans are required to confirm these findings.

Predictive Value of Tissue-induced Oxidative Stress on Urogynecology Synthetic Graft Reinforcement: An Experimental Animal Study

Background: The success of urogynecology synthetic grafts depends on adequate tissue reinforcement. This experimental animal study aimed to determine the abdominal wall reinforcement achieved by different urogynecology synthetic grafts, including the influence of inflammatory cells, collagen deposits, and tissue-induced oxidative stress. Methods: Electron microscopic analysis of six different grafts, all with Polypropylene as their major component, was performed to determine the primary mesh characteristics. Full-thickness abdominal wall defects were repaired using monofilament, multifilament, and coated grafts in male Wistar rats. After six weeks, the animals were sacrificed and the inflammatory response, collagen deposition, and oxidative stress levels were quantified. Using the digital acquisition system (Hottinger Baldwin Messetechnik (HBM) “Catman Easy”, Darmstadt, Germany), mechanical testing of the native grafts and of the reinforced abdominal wall was conducted and measured in a controlled environment. Multivariate analysis was performed to determine the predictive value of inflammatory cell numbers, collagen amount, oxidative stress, and native graft strength on the final abdominal wall reinforcement. Results: The inflammatory response was significantly more prominent with the multifilament polypropylene compared to the low-weight monofilament polypropylene (p < 0.05). Collagen deposits varied between the groups, reaching statistical significance only for multifilament polypropylene vs. titanium-coated polypropylene (p < 0.05). The oxidative stress results demonstrated a positive correlation with graft weight, regardless of coating or different graft structures (p < 0.05). The number of inflammatory cells and collagen amount did not influence the final abdominal reinforcement, while tissue-induced oxidative stress presented with a negative influence in all groups. Conclusions: Tissue-induced oxidative stress negatively affected grafts in this animal experiment. This finding might be useful (at least partially) in predicting the effectiveness of urogynecology synthetic graft tissue reinforcement and also, in promoting this reinforcement.

Reducing Complications and Expanding Use of Robotic Rectus Abdominis Muscle Harvest for Pelvic Reconstruction.

The rectus abdominis flap has long been a workhorse in perineal reconstruction. Although traditionally approached though an external incision, the morbid nature of the incision and subsequent violation of the anterior rectus sheath has encouraged innovation of minimally invasive approaches for harvest. In this study, we present our experience, evolution, and comparative outcomes of robotic rectus abdominis muscle harvest. A retrospective review of perineal reconstruction was performed for a 6-year period (2014 to 2019). Robotic rectus abdominis muscle flaps were compared to nonrobotic techniques performed during this time. Descriptive statistics and complication profiles were computed. The details of our surgical technique are also described. Thirty-six patients underwent perineal reconstruction. Sixteen were performed using the robotic rectus abdominis muscle and 20 with traditional repairs (12 vertical rectus abdominis myocutaneous flaps and eight gracilis flaps). Demographic profiles were similar between cohorts, including age, body mass index, smoking, diabetes, neoadjuvant radiation therapy, and need for vaginal wall repair. Six robotic patients underwent abdominal wall reinforcement with biological mesh. Length of stay, surgical times, and incidence of major complications were similar between cohorts with a trend toward increased minor complications in traditional reconstructions (55 percent versus 31 percent; p = 0.15). Robotic rectus abdominis muscle harvest is a powerful tool that continues to evolve the potential to mitigate common morbidities and complications of traditional repair and further enhance cosmetic outcomes. This study suggests that greater flexibility for reconstruction can be afforded with harvest of the posterior rectus sheath and complications avoided with prophylactic mesh reinforcement. Therapeutic, III.

An evaluation of clinical and quality of life outcomes after ventral hernia repair with poly-4-hydroxybutyrate mesh.

Despite continued efforts, recurrence after ventral hernia repair (VHR) remains a common problem. Biosynthetic Phasix™ (Poly-4-Hydroxybutyrate, P4HB) mesh combines the durability of synthetic mesh with the bio-resistance of biologics. P4HB has shown promising early outcomes, but long-term data are lacking. We examine patients following VHR with P4HB with at least 3years of follow-up to assess clinical and patient reported outcomes (PROs). Adult patients (≥ 18years old) undergoing VHR with P4HB mesh between 10/2015 and 01/2018 by a single surgeon were retrospectively identified. Patients with < 36months of follow-up were excluded unless they had a documented recurrence. Clinical outcomes and quality of life using the Hernia-Related Quality of Life Survey (HerQLes) were assessed. Seventy-one patients were included with a median age and body mass index of 61.2 and 31kg/m2, respectively. Mesh was placed in the retromuscular (79%) and onlay (21%) planes with 1/3 of patients having hernias repaired in contaminated fields. There were no mesh infections, enterocutaneous fistulas, or mesh explantations. Nine patients (12.7%) developed recurrence at a median follow-up of 43.1months [38.2-49.1]. Mesh plane, fixation technique, and Ventral Hernia Working Group were not associated with recurrence. Significant improvement in disease-specific PROs was observed and maintained at 3-year follow-up. Longitudinal clinical and quality of life outcomes after clean and contaminated VHR with P4HB are limited. Here, we conclude that P4HB is an effective and versatile mesh option for use in abdominal wall reinforcement.

Heterologous Bovine Tunica Albuginea Graft Conserved in Honey as Abdominal Wall Reinforcement in Rats

Complex abdominal wall defects might be challenging for human and veterinary surgeons worldwide. Defects from trauma or congenital causes may lead to hernias development. The introduction of meshes to reinforce hernia repairs has improved surgical outcomes and several synthetic and biologic materials have been used. In this context, biomaterial prosthesis seems to be a satisfactory solution when managing great abdominal wall defects. The aim of the current study is to evaluate the bovine tunica albuginea (BTA) preserved in honey as graft material for rats’ abdominal wall reinforcement in incisional herniorrhaphy surgery as well as its viability, cicatrization and integration into the host tissue. Wistar rats were assigned to two main groups: 1) animals (n = 20) underwent median longitudinal laparotomy followed by laparorraphy with suture of the bovine tunica albuginea (BTA) graft as abdominal wall reinforcement; and 2) animals (n = 20) underwent only laparotomy and subsequent laparorrhaphy. Rats were clinically evaluated until euthanasia at post-surgical day 7, 14, 21 and 28. Necropsy and histopathological analysis of abdominal wall fragments were performed to compare groups and subgroups findings. BTA promoted abundant fibrosis, providing resistance and low postoperative complication rates. Besides, animals did not show rejection signs to the implant. In conclusion, BTA preserved in honey is an affordable, easy collection and handling biomaterial for graft, demanding simple surgical implantation technique for abdominal wall repair in rats.

Minimally invasive correction of anatomical features of anterior abdominal wall and ventral hernias

Conventional «open» procedures for ventral hernias and diastasis recti are widely known, used everywhere and have a great number of author's improvements related to surgeon's experience, availability of modern information, equipment and materials. K. LeBlanc and W. Booth (1993) reported IPOM-method with non-adhesive coating that is considered a milestone in surgery of anterior abdominal wall and ventral hernia. This technique has gained recognition among surgeons around the world due to its technical simplicity, minimal invasiveness and high reproducibility. However, certain disadvantages of this technique have been shown over the past time that justified advisability of searching for another methods of anterior abdominal wall reinforcement. Thus, E-Milos, LIRA, TESAR, eTEP, REPA, TARM, TARUP techniques are currently available. This review is devoted to technical features of these techniques, their potential advantages and disadvantages.

Repair of the Severe Muscle Aponeurotic Abdominal Laxity with Alloplastic Mesh in Aesthetic Abdominoplasty.

Abdominoplasty is the most frequently performed surgical procedure for body contour; in our experience, we have observed some patients with prominent bulging that is difficult to treat and that presents results that are unsatisfactory or have recurrences to conventional treatments. This leads us to carry out an analysis of the elements responsible for the containment and abdominal format. We determined that it may be due to an inability of an important sagging aponeurotic muscle of primary origin to support the abdomen and could be caused by predisposing factors. For these specific cases, we developed a treatment proposing the use of a mesh. We present these cases over a period of 24years. Fourteen patients were treated with primary and secondary abdominoplasties. The abdominal wall reinforcement was performed by placing polypropylene mesh at the sub-muscular plane, fixed with U-stitches on the fascia transversalis, seeking to strengthen the muscle and the fascia transversalis. The results were satisfactory after long-term observation, gaining resolution of the abdominal bulges. Only two complications occurred; the presence of localized chronic pain and the appearance of umbilical fistula. We emphasize the importance of avoiding unnecessary interventions in patients with marked bulging, associated with inability of abdominal restraint. We only consider its indications in patients with conventional recurrence treatment, also identifying the predisposing factors, the knowledge of the abdominal anatomy, the muscular dynamics of the abdomen and understanding its indication in these specific cases of difficult treatment. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abdominal Bulge After Retroperitoneal Dissection

Abdominal bulge after retroperitoneal dissection occurs at a rate of 1% to 56%. Injury to the T11 and T12 nerves is thought to result in abdominal musculature denervation, laxity, and symptomatic abdominal bulge. This complication has become more prevalent because the retroperitoneal approach for spinal surgery has become the preferred approach in specific lumbar and thoracic cases. Current repair techniques fail to address the etiology of abdominal wall laxity, and outcomes are poorly reported. Recurrence rates in lateral abdominal bulge repair are reported between 0% and 100%, and the complication rate is nearly 25%. We present a method of bone anchored fixation of mesh for abdominal wall reinforcement after the imbrication of the atrophied musculature, resulting in the definitive treatment of abdominal bulge after retroperitoneal dissection. A retrospective review of 4 consecutive patients who underwent bony fixation of mesh using Mitek suture anchors (De Puy, Raynham, MA) for abdominal bulge after retroperitoneal dissection between February 2013 and September 2014 was performed. The preoperative, intraoperative, and postoperative records of 4 patients were reviewed and compared. There were no reported early recurrences and no perioperative morbidity or mortality related to the operation. Average follow-up was 12.8 months (range, 6-26 months); operative time, 157 minutes; postoperative length of stay, 3.5 days; and estimated blood loss was 50 mL. Reinforcement of the myofascial repair using bone anchored fixation of mesh represents a novel approach for the treatment of abdominal bulge after retroperitoneal dissection. Results demonstrate safety and no early recurrence.

Primary Abdominal Wall Reinforcement With Synthetic Mesh Following Harvesting Of Vertical Rectus Abdominis Myocutaneous Flaps In Multivisceral Pelvic Resections

Primary Abdominal Wall Reinforcement With Synthetic Mesh Following Harvesting Of Vertical Rectus Abdominis Myocutaneous Flaps In Multivisceral Pelvic Resections

Biologic mesh versus synthetic mesh in open inguinal hernia repair: system review and meta-analysis.

Biologic meshes are mostly used for abdominal wall reinforcement in infected fields, but no consensus has been reached on its use for inguinal hernia repairing. The purpose of this study was to compare biologic mesh with synthetic mesh in open inguinal herniorrhaphy. A systematic literature review and meta-analysis was undertaken to identify studies comparing the outcomes of biologic mesh and synthetic mesh in open inguinal hernia repair. Published studies were identified by the databases PubMed, EMBASE and the Cochrane Library. A total of 382 patients in five randomized controlled trials were reviewed (179 patients in biologic mesh group; 203 patients in synthetic mesh group). The two groups did not significantly differ in chronic groin pain (P = 0.06) or recurrence (P = 0.38). The incidence of seroma trended higher in biologic mesh group (P = 0.03). Operating time was significantly longer with biologic mesh (P = 0.03). There was no significant difference in hematomas (P = 0.23) between the two groups. From the data of this study, biologic mesh had no superiority to synthetic mesh in open inguinal hernia repair with similar recurrence rates and incidence of chronic groin pain, but higher rate of seroma and longer operating time. However, this mesh still needs to be assessed in a large, multicentre, well-designed randomized controlled trial.

Emerging Trends in Abdominal Wall Reinforcement: Bringing Bio-Functionality to Meshes.

Abdominal wall hernia is a recurrent issue world-wide and requires the implantation of over 1 million meshes per year. Because permanent meshes such as polypropylene and polyester are not free of complications after implantation, many mesh modifications and new functionalities have been investigated over the last decade. Indeed, mesh optimization is the focus of intense development and the biomaterials utilized are now envisioned as being bioactive substrates that trigger various physiological processes in order to prevent complications and to promote tissue integration. In this context, it is of paramount interest to review the most relevant bio-functionalities being brought to new meshes and to open new avenues for the innovative development of the next generation of meshes with enhanced properties for functional abdominal wall hernia repair.

Clinical application of a silk fibroin protein biologic scaffold for abdominal wall fascial reinforcement.

Background:Preclinical studies have demonstrated that macroporous silk fibroin protein scaffolds are capable of promoting physiologically durable supportive tissue, which favors application of these engineered tissues for clinical implantation. The safety and effectiveness of a long-lasting, transitory, 510(k)-cleared purified silk fibroin biologic scaffold (SBS) are investigated for soft-tissue support and repair of the abdominal wall.Methods:We conducted a multicenter retrospective review of all consecutive patients who underwent abdominal wall soft-tissue reinforcement with an SBS device between 2011 and 2013. Indications, comorbid conditions, surgical technique, complications, and outcomes were evaluated.Results:We reviewed the records of 172 consecutive patients who received an SBS for soft-tissue support. Of those, 77 patients underwent abdominal wall fascial repair, with a mean follow-up of 18.4 ± 7.5 months. Procedures using an SBS included reinforcement of an abdominal-based flap donor site (31.2%), ventral hernia repair (53.2%), and abdominoplasty (15.6%). The overall complication rate was 6.5%, consisting of 2 wound dehiscences, 1 with device exposure, 1 seroma, 1 infection with explantation, and a perioperative bulge requiring reoperation. There were no reports of hernia.Conclusions:Postoperative complication rates after 18 months were low, and most surgical complications were managed nonoperatively on an outpatient basis without mesh removal. To our knowledge, this is the only series to report on a long-lasting, transitory SBS for abdominal wall repair and reinforcement. Procedure-specific outcome studies are warranted to delineate optimal patient selection and define potential device characteristic advantages.

Inguinal hernia repair using a synthetic long-term resorbable mesh: results from a 3-year prospective safety and performance study.

PurposeConventional meshes for hernia repair and abdominal wall reinforcement are usually made from polypropylene, polyester or other synthetic plastic materials known to promote foreign body reactions and a state of chronic inflammation that may lead to long-term complications. A novel approach is to use long-term resorbable implants like TIGR® Matrix Surgical Mesh. Preclinical studies have shown that this mesh maintains mechanical integrity beyond the point in time where newly formed tissue is capable of carrying the abdominal loads.MethodsThis was a first-in-man, prospective, pilot study performed during 2009, at two sites in Sweden. Forty patients with primary inguinal hernias were enrolled for Lichtenstein repair using TIGR® Matrix Surgical Mesh. The primary endpoint was safety as assessed by monitoring the incidence of adverse events and serious adverse events (SAEs) both related and unrelated to the mesh. The secondary endpoint was pain or discomfort. Visual Analogue Scale (VAS) 0–10 and Inguinal Pain Questionnaire were used for scoring pain and discomfort. Included patients have been followed for 36 months using ultrasound in combination with clinical examination.ResultsAll patients followed a normal early postoperative course. After 12 months no SAEs were reported. None of the patients with an isolated lateral inguinal hernia (LIH) had developed a recurrence but 4 (44 %) with medial and 4 (33 %) with combined hernias had recurred at 36-month follow-up. After 3-year follow-up none of the patients with LIH reported pain in the VAS-form and none of those patients could feel the sensation of a mesh in their groin. In the total study population 5 (16 %) patients experienced chronic pain in the form of mild sporadic pain and 3 (9.7 %) patients could feel the sensation of a mesh in their groin.ConclusionThe use of a synthetic long-term resorbable mesh (TIGR® Matrix Surgical Mesh) in Lichtenstein repair was found to be safe, without recurrences, and promising regarding pain/discomfort at 3-year follow-up in patients with LIH. However, patients with medial and combined inguinal hernias had high recurrence rates.

A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields

Guidelines recommend the use of bioprosthetics for abdominal wall reinforcement in contaminated fields, but the evidence supporting the use of biologic over synthetic non-absorbable prosthetics for this indication is poor. Therefore, the objective was to perform a systematic review of outcomes after synthetic non-absorbable and biologic prosthetics for ventral hernia repair or prophylaxis in contaminated fields. The systematic literature search identified all articles published up to 2013 that reported outcomes after abdominal wall reinforcement using synthetic non-absorbable or biologic prosthetics in contaminated fields. Studies were included if they included at least 10 cases (excluding inguinal and parastomal hernias). Quality assessment was performed using the MINORS instrument. The main outcomes measures were the incidence of wound infection and hernia at follow-up. Weighted pooled proportions were calculated using a random effects model. A total of 32 studies met the inclusion criteria and were included for synthesis. Mean sample size was 41.4 (range 10-190), and duration of follow-up was >1year in 72% of studies. Overall quality was low (mean 6.2, range 1-12). Pooled wound infection rates were 31.6% (95% CI 14.5-48.7) with biologic and 6.4% (95% CI 3.4-9.4) with synthetic non-absorbable prosthetics in clean-contaminated cases, with similar hernia rates. In contaminated and/or dirty fields, wound infection rates were similar, but pooled hernia rates were 27.2% (95% CI 9.5-44.9) with biologic and 3.2% (95% CI 0.0-11.0) with synthetic non-absorbable. Other outcomes were comparable. The available evidence is limited, but does not support the superiority of biologic over synthetic non-absorbable prosthetics in contaminated fields.

Reinforcement of the Abdominal Wall following Breast Reconstruction with Abdominal Flaps

Breast reconstruction using muscle-preserving abdominal flaps occasionally results in an abdominal bulge or hernia. The authors analyzed outcomes and complications following use of a synthetic or biological mesh for abdominal reinforcement following initial harvest or secondary repair of a bulge or hernia. A retrospective review was conducted of all patients (n = 818) who had abdominal flap-based breast reconstruction between 1995 and 2011. Ninety-seven patients met inclusion criteria; 61 had synthetic mesh and 36 had biological mesh (porcine acellular dermal matrix). Complications and outcomes were reviewed. Statistical analysis was performed to determine contributing factors and differences between cohorts. Overall complication rates for the synthetic and biological cohorts were 6.5 and 5.5 percent (p = 0.61), respectively, with slightly higher bulge rates in patients with synthetic compared with biological mesh (18 percent versus 8.3 percent; p = 0.25). Complication rates in primary and secondary placement of synthetic mesh were 5 and 7.3 percent, respectively; bulge rates were 15 and 19.5 percent, respectively. Complication rates in primary and secondary placement of biological mesh were 6.3 and 0 percent, respectively; bulge rates were 9.4 and 0 percent, respectively. Synthetic and biological mesh reconstruction for primary abdominal repair and secondary contouring have similar, low complication rates. Postoperative abdominal wall laxity and bulge occurred in an equal distribution following unilateral or bilateral flap reconstruction. Early investigation demonstrates that porcine acellular dermal matrix is as effective as synthetic mesh for abdominal wall reinforcement and repair, with limited morbidity associated with each. Therapeutic, III.

Initial Experience With the Use of Porcine Acellular Dermal Matrix (Strattice) for Abdominal Wall Reinforcement After Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

Reestablishing anterior rectus fascial integrity remains a clinical challenge after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The main concerns include herniation and bulging due to abdominal weakness. Mesh-assisted closure of the fascial defect has improved bulging and herniation rates but infection, extrusion, and encapsulation are serious concerns with mesh use. Biologic tissue matrices may overcome some of these mesh-related complications. The initial experience of using Strattice for fascial closure after TRAM flap procedure is described in this article. Strattice was in-lain and sutured between the anterior and posterior layers of the rectus fascia, at the rectus muscle donor site. The abdominal wall was closed with progressive tension sutures. Postoperative complications at the donor site were assessed. A total of 16 unilateral and 9 bilateral reconstructions were performed in 25 patients. Length of hospital stay was 2 to 3 days which is shorter than with mesh repair (typically 4-5 days). During a mean follow-up period of 14.0 months, complications occurred in 7 patients (28%): seroma formation (2), minor skin separation (2), superficial skin infection (2), and superficial wound dehiscence (1). Complications were not directly related to Strattice and all, except one (superficial skin infection), were resolved without surgical intervention. In all patients, routine abdominal functions were restored 4 months postoperatively. Strattice is a safe, alternative option to synthetic mesh for fascial repair following TRAM flap breast reconstruction. When used in conjunction with progressive tension suture closure of the abdominal wall, dynamic reconstruction of the abdominal wall with resumption of abdominal function is possible with Strattice.

Subxiphoid incisional hernias after median sternotomy

Subxiphoid incisional hernias are notoriously difficult to repair and are prone to recurrence. The few reports on subxiphoid hernia published over the last two decades have not fully addressed the etiology, pathology, treatment, and outcome of this problem. This review was performed to analyze the published experience and increase the understanding of these difficult hernias. We reviewed the extensive literature, including the Medline and Current Contents computerized database searches, and searched the available bibliographies. Seven retrospective studies of a total of 113 patients who had clinical subxiphoid hernias after median sternotomy were found. An additional surgical technique describing a modified median sternotomy preventing the hernia, and a single review article on selected technical considerations of subxiphoid ventral repair were also found. The incidence of subxiphoid hernia after median sternotomy can be possibly reduced by paraxiphoid extension of the sternotomy, reinforcement near the xiphoid end of the incision, or by optimizing closure of the distal sternotomy and the linea alba. Abdominal wall reinforcement by open-mesh closure or laparoscopic transperitoneal prosthetic repair can effectively deal with the defect. Long-term outcome analyses are not yet available.