Hernioplasty Technique Research Articles

Novel Transabdominal Preperitoneal Hernioplasty Technique for Recurrent Inguinal Hernia: Overlapping of Whole Posterior Wall with Newly Added Mesh and Pre-Existing Mesh by Closing Hernia Defect.

Purpose: In some patients with recurrent inguinal hernias who have undergone previous laparoscopic herniorrhaphy, dissecting the entire posterior wall is difficult due to mesh adhesion. We applied a novel transabdominal preperitoneal (TAPP) hernioplasty technique that involves closing of the hernia defect and implantation of a newly added mesh while preserving the pre-existing mesh for inguinal hernia recurrence after laparoscopic herniorrhaphy. This study was performed to evaluate this novel technique for treatment of recurrent inguinal hernias. Methods: We evaluated 24 adult patients (23 male, 1 female; mean age, 55.8 ± 14.0 years; range, 26-77 years) with recurring inguinal hernias. A modified TAPP (mTAPP) procedure involving closing of the defect and implantation of an 8 × 6-cm2 newly added mesh was performed. The new technique covered the whole posterior wall with pre-existing mesh. Results: Among the 24 patients, there were 12 direct hernias and 12 indirect hernias. The mean postoperative pain scores after 1 week were 2.5 and 2.0 in patients with direct and indirect hernias, respectively, and the mean duration until return to normal activities was 8.5 and 7.5 days in patients with direct and indirect hernias, respectively. The mean follow-up period was 21.0 ± 17.0 (range, 2-56) months. No chronic inguinodynia or rerecurrence was observed. Conclusions: In this novel mTAPP procedure for recurring inguinal hernias, closing sutures prevented mesh migration, and complete posterior wall overlap was possible using the pre-existing mesh and newly added mesh. The mTAPP procedure was an effective operation with few recurrences and complications.

Inguinal hernias recurrence: causes and surgical treatment

The current paper reveals the definition and classification of recurrent inguinal hernia, the main causes of relapses are highlighted. According to modern data, the relapse causes are divided into three groups: factors caused by the general condition of the patient, morphological features of the primary hernia, and factors that depend on the attending physician. The dependence of the relapses occurrence on the technical errors of the surgeon has been analyzed. Particular attention is paid at the correctness of the certain hernioplasty technique implementation, the surgeon’s experience, the effective treatment method choice of the primary inguinal hernia. The attention is focused on the recurrence mechanisms after endoscopic methods for primary inguinal hernias, which have been increasingly used in general surgical practice. It presents the evolution of improvement laparoscopic plasty techniques to reduce the complications number and relapse rate: using a larger mesh, reducing the taker amount during fixation or the use of methods without fixation with fibrin glue, the entire mesh plastic without cutting it, which prevents relapses at the site of the mesh section. Approaches to the selection of a reliable hernioplasty technique for reducing the number of relapses have been presented. The data are based on the national Swedish and the Danish registers, recommendations of the EHS, according to which it is required to select an alternative mesh placement method to the previous alloplasty for the treatment of relapsing inguinal hernia, the latter allows to use less modified muscle‑aponeurotic structures in the treatment of recurrent inguinal hernias. In this case, special attention should be paid at the sufficient mesh overlapping of scar and atrophied tissues in the inguinal area. The matter of surgical treatment of recurrent inguinal hernias remains up‑to‑date and addresses further improvement.

Modified three-stitch hernioplasty technique.

We read with great interest the article by Patchayappan et al., concerning the three-stitch hernioplasty, where the prolene mesh is fashioned as in Lichtenstein's repair, placed, and fixed only by three prolene stitches. We agree with the authors as we are using a similar technique with some technical differences.

“All-in-one mesh” hernioplasty: A new procedure for primary inguinal hernia open repair

We propose a new open mesh hernia repair procedure for the treatment of inguinal hernias in adults aiming to improve patients' comfort and to reduce the incidence of chronic neuralgia. From September 2012 to August 2015, 250 consecutive patients were treated with "all in-one" mesh hernioplasty procedure in our Institution. According to the devised technique, a new smaller prosthesis was placed on the floor of the inguinal canal in order to strengthen all areas of weakness from which hernias may originate. The mesh was enveloped by a fibro-cremasteric sheath avoiding contact with neural structures. Follow-up was carriedout at 3, 6, 12, 18 and 24 months for evaluation of postoperative pain using VisualAnalogue Scale score, need of medication, patients' comfort and short or long-term complications. All patients were discharged within 24h from surgery. Slight pain was reported by the majority of patients and 47.6% of them did not require pain medication at home. After the 1st postoperative week 96.8% reported no pain and no other symptoms. No relevant limitation of normal activities was reported. There has been no postoperative neuralgia. One recurrence was observed. This new hernioplasty technique respects the anatomy of the inguinal canal, uses a smaller mesh, and seems to avoid neuralgia with maximum comfort for the patients.

Intraoperative Inguinal Measurements to Estimate a Single Optimal Mesh Size for Lichtenstein Inguinal Hernioplasty: an Observational Study

In inguinal hernia surgery, use of optimal mesh size during Lichtenstein hernioplasty technique is essential in preventing recurrence. This study was an attempt to determine a single optimal mesh size which can be adapted in vast majority of cases based on intraoperative inguinal measurements. This observational study was done for 1 year in the Department of Surgery, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India. A total of 60 patients aged above 18 years who were scheduled for elective inguinal hernioplasty using the Lichtenstein technique for direct or indirect inguinal hernia were subjected to intraoperative measurements. All the patients were male with mean age of 52.75 ± 15.39 years. Mean body mass index (BMI) was 24.51 ± 3.10 kg/m2. With regard to hernia characteristics, most of the patients had right-sided hernia (61.7%), indirect (51.67%), and incomplete hernia (81.67%). The mean width of mesh required was 6.65 ± 0.24 cm and mean length was 13.75 ± 0.25 cm. The mesh size was comparable with respect to demographic characteristics, anthropometry, BMI, and type and extent of hernia (p > 0.050) but age and length of mesh size varied significantly in patients with direct and indirect type of hernia (p < 0.050). The present study made an attempt to determine a single optimal mesh size in cases who underwent inguinal hernia repair based on the principles of Lichtenstein hernioplasty, which being 6.7 cm × 13.8 cm. Another significant finding was varying in mesh length size between direct and indirect hernias.

La «invasividad» de las técnicas quirúrgicas en el tratamiento de las hernias de la región inguinal

Developments in inguinal hernioplasty techniques have sought, among other factors, to reduce the aggressiveness of the surgical approach. Thus, access may be invasive, miniinvasive or minimally invasive according to incision size. However, the concept of surgical aggression is often erroneously interpreted as the insult produced by the route of tissue access without considering the impact of the tissue dissection produced in the groin area. This misleading interpretation has been more obvious for some techniques ranging from the extensive approach of the Stoppa technique to the minimal approaches of today's videoscopic techniques. Thus, these videoscopic techniques have been interpreted and described as minimally invasive and scarcely aggressive while there is little argument that the surgical field they create is one of extensive aggressive tissue dissection.To assess the general surgical insult produced by a hernia repair technique, this study proposes the classification of these techniques according both to the size (quantitative) of the surgical access incision (as maxi-, normo- or miniinvasive), and the extension (qualitative) of tissue dissection produced (as mini-, normo- or maxidissective).Using this system, each technique can be classified so that the surgeon will have a real objective idea of the overall tissue damage a given procedure will induce. This additional information will help in choosing the most appropriate hernioplasty method in each case.

The technical characteristics and immediate results of laparoscopy trans-peritoneal and total extra-peritoneal hernioplasty

Over the time of recent years, in surgical treatment of inguinal hernia such revolutionary changes occurred as implementation of Lichtenstein's nonstrain prosthetic inguinal hernioplasty (1986) into surgical practice and application of laparoscopic hernioplasty (Arregui M.E., 1992; McKernan and Ferzli, 1993). The study was carried out to evaluate reliability and effectiveness of application of trans-peritoneal and total extra-peritoneal hernioplasty in case of inguinal hernia. During 2012-2015, in the municipal clinical hospital №4 and the Russian gerontological research clinical center (Moscow) 12 patients underwent 12 hernioplasties using technique of total extra-peritoneal hernioplasty and 65 patients underwent 73 hernioplasties using technique of trans-peritoneal hernioplasty (in 8 cases herniae were bilateral). The technical intra-operational characteristics of procedures were analyzed. The evaluation of intra-operational and post-operational complications during earlier post-operational period and in a year after operation was carried out. The single patient in the group of total extra-peritoneal hernioplasty inguinal hernia was relapsing after herniotomy with plasty with local tissues. All herniae were one-sided. The average duration of operation made up to 62.5 minutes. The conversion was never required. In the group of trans-peritoneal hernioplasty average duration of operation made up to 58.5 minutes. The conversion was never required too. The rate of intra-operational complications in both groups was low. The most of the patients in main group (total extra-peritoneal hernioplasty) were ready to be discharged from the hospital at second day after operation. The total rate of post-operative complications made up to 20.6%. Only in the group of trans-peritoneal hernioplasty single relapse was observed after three months after operation. According to results of study, the laparoscopic inguinal hernioplasty is the most preferable and rational treatment of most of the types of inguinal herniae. The total extra-peritoneal hernioplasty is more preferable than trans-peritoneal hernioplasty because of number of reasons i.e. the post-operative pain is less expressed; operation is performed in retroperitoneal way; the risk of damaging of internal organs and development of peritoneal commissures is minimized.

Early results of dual approach hernioplasty(DAH): an innovative laparoscopic inguinal hernioplasty technique.

In this study, the proposed technique is combining the invented method of extraperitoneal dissection utilizing gas insufflation through Veress needle introduced from the groin with the transabdominal approach. Such a combination minimizes operative demands, achieves major goals, and reduce operative time in an attempt to improve laparoscopic hernioplasty techniques. The study recruited 211 patients having primary reducible inguinal hernia upon first diagnosis. Abdominal ultrasound examination achieved to exclude any additional pathology and confirming clinical diagnosis. The new technique is applied on all patients without any modification through the whole series. Patients' epidemiology, operative characteristics, and follow-up are all tabulated. Results showed no complications nor conversion to open procedure. The proposed procedure showed preliminary encouraging results regarding technique, clinical outcome, time-saving, and patients' safety. Combination of extraperitoneal gas-derived dissection, transabdominal field review, and preperitoneal mesh application offers an innovative and promising laparoscopic hernioplasty technique. The study is introducing the technique and as well invites further trials on wider scale to verify the technique.

A comparative study between laparoscopic intraperitoneal onlay mesh hernioplasty and open underlay mesh hernioplasty for ventral hernias

Background: Even after nearly two decades of experience with laparoscopic ventral hernia repair, there is a surprising paucity of good data clearly proving the benefits of this technique over standard open procedure. The aim of this prospective study was to analyse the surgical technique and perioperative outcomes of laparoscopic intraperitoneal onlay mesh hernioplasty in comparison with the open underlay mesh hernioplasty for ventral hernias. Methods: Sixty patients with ventral hernia included in this study were divided into two groups after randomisation. Study group patients underwent laparoscopic intraperitoneal mesh hernioplasty and control group patients underwent open underlay mesh hernioplasty. Follow-up was done for a period of 6 months and the intraoperative and postoperative outcomes were compared. Results: Patients operated by laparoscopic ventral hernia repair and open underlay mesh hernioplasty were comparable with respect to age, sex, comorbidities, previous history of abdominal surgery, body mass index and size of defect. The laparoscopic approach was associated with shorter operative time, lower blood loss and lesser postoperative pain requiring opioid analgesics for a shorter duration compared to the open approach. Also the length of hospital stay and duration of antibiotic requirement was less with laparoscopic approach. Incidence of seroma and recurrence was lower in the laparoscopic group. Conclusions: Laparoscopic ventral hernia repair although technically demanding, is safe and feasible. It has fewer complications and a better postoperative course, with shorter operative time, less blood loss, lesser postoperative pain, quicker ambulation and shorter duration of hospital stay.

A human case study demonstrating the safety and effectiveness of laparoscopic surgical glue injection hernioplasty for pediatric indirect inguinal hernia

The purpose of this pediatric case report was to provide clinical evidence supporting the safety and effectiveness of laparoscopic surgical glue injection hernioplasty (LSGIH) in humans for indirect inguinal hernia repair. We performed LSGIH on a female newborn for a right indirect inguinal hernia that was incidentally discovered during a laparoscopic right salphingo-oophorectomy for prenatal right ovarian cyst torsion. Under laparoscopic control, the internal ring was closed by injection of Histoacryl into the internal opening of the patent processus vaginalis. One month later, the patient underwent another laparoscopic operation due to torsion of a newly developed contralateral ovarian cyst. During the second operation, we were able to clearly observe the previous LSGIH site. Despite partial absorption of the injected Histoacryl , the opening of the internal ring remained closed without any evidence of adhesions. This case supports LSGIH as a simple, safe, and useful technique for pediatric inguinal hernioplasty. However, more clinical trials should be performed to confirm the long-term reliability and safety of LSGIH in humans.

Connective tissue features influencing the results of abdominal hernia repair

Nowadays connective tissue disorders are considered to play a great role in abdominal hernia formation and recurrence. Benign hypermobility syndrome is associated with diffe-rent diseases of locomotive system (flat foot, scoliosis), varices of lower extremities, progressive myopia, mitral valve prolapse, tracheobronchomalacia etc. This predisposing factor favors abdominal wall debilitation, anatomical aperture’s enlargement and hernia formation. As a result, benign hypermobility syndrome hampers the post-operative scar organization even in small-sized hernias and is an important risk factor of abdominal hernia recurrence. That is why the individual choice of abdominal hernioplasty technique is justified. There is no established optimal technique of abdominal hernioplasty allowing no complications and recurrences. Thus, the understanding of morphological manifestations of tissue reaction inside the mesh endoprosthesis particularities may become of great importance to prevent abdominal hernioplasty complications. Abdominal hernioplasty technique choice is based on individual selection of endoprosthesis, depending on individual characteristics of patient’s connective tissue, abdominal hernioplasty method and endoprosthesis tendency to shrinking in late postoperative period.

Evaluation of testicular perfusion with color and pulsed Doppler ultrasonography after “standing laparoscopic peritoneal flap hernioplasty technique”

Evaluation of testicular perfusion with color and pulsed Doppler ultrasonography after “standing laparoscopic peritoneal flap hernioplasty technique”

Standing Laparoscopic Peritoneal Flap Hernioplasty Technique for Preventing Recurrence of Acquired Strangulating Inguinal Herniation in Stallions

To describe a standing laparoscopic peritoneal flap hernioplasty (PFH) technique for closure of the vaginal ring, and to evaluate its effect on prevention of recurrent herniation in stallions, previously treated for acquired strangulating inguinal hernia (SIH). Case series. Stallions (n = 30) aged 3-15 that had previous acquired SIH. Bilateral standing laparoscopic PFH was performed on 30 stallions that had previous acquired SIH treated without castration. The vaginal rings were approached from 3 portals, 2 in the paralumbar fossa and a 3rd between the 17th and 18th ribs on the ipsilateral side. A large inverted U-shaped peritoneal flap was dissected from the abdominal wall proximal and cranial to the vaginal ring, reflected caudally over the vaginal ring, and secured to the abdominal wall with laparoscopic staples. In the first 11 stallions, only the cranial and mid third of the vaginal ring was covered. For the next 19 stallions, complete closure of the vaginal ring including the entire caudal aspect of the vaginal ring was achieved. SIH recurrence occurred in 4 of 11 stallions with incomplete ring closure whereas no SIH recurrence occurred when the entire vaginal ring was closed. No major complications occurred and cosmetic outcome was excellent. All breeding stallions were successfully used for breeding. Standing laparoscopic closure of the vaginal ring using a PFH is an effective way to prevent recurrence of SIH provided the entire vaginal ring, including the caudal aspect is covered by the flap. There seems to be no effect on subsequent fertility.

Fibrin sealant in inguinal hernioplasty: an observational multicentre study in 1,201 patients

PurposeA prospective, multicentre, observational study was undertaken to assess Tisseel® fibrin sealant for atraumatic mesh fixation in inguinal hernia repair throughout France.MethodsSurgeons recorded data on patients undergoing tension-free inguinal hernioplasty with mesh fixation with Tisseel®, regardless of the hernioplasty technique used. Assessments were made at 2 days and 1 month after surgery. Data on local complications, operation times and ease of product use were collected.ResultsIn total, 1,201 patients were recruited (90% men, mean age 57 years), among which 526 procedures were performed using open techniques and 675 using laparoscopic repairs. Local complications occurred in 4.7% of patients: 3.0% haematoma, 1.4% seroma, 0.3% recurrence. The mean visual analogue scale (VAS)-rated pain scores were 3.2 pre-operatively, 2.3 immediately after surgery and 1.8 at 1 month. Surgeons rated the product as very easy to use.ConclusionsTisseel® fibrin sealant appears to be a well-tolerated and easy-to-use alternative to traditional, tissue-penetrating devices for mesh fixation in hernia repair techniques.

Laparoscopic Mesh Incisional Hernioplasty in Five Horses

To report a technique for incisional hernioplasty in horses using laparoscopic placement of a prosthetic mesh. Case series. Horses (n=5) with ventral median abdominal incisional hernia. A telescope and 2 instrument portals were established bilaterally, lateral to and distant from the hernia margins. After exposure of the internal rectus sheath by removal of retroperitoneal fat with endoscopic scissors and monopolar cautery, a prosthetic mesh was introduced into the abdomen and secured intraperitoneally using transfascial sutures with or without supplemental endoscopic hernia fixation devices. Successful placement of the prostheses was achieved without major intra- or postoperative complications. Repairs were intact in all horses (follow-up range: 6-23 months) without evidence of adhesion formation. Cosmetic results compared favorably with those typically achieved using conventional, open hernioplasty techniques. Incisional hernia repair in horses can be successfully achieved with a laparoscopic intraperitoneal mesh onlay technique. Laparoscopic mesh hernioplasty has promise as a safe and effective method for repair of incisional hernias in horses.

A long-term evaluation of the modified mesh-plug hernioplasty in over 2,000 patients

A modified technique for mesh-plug hernioplasty is a long-term, safe and efficacious treatment for primary unilateral inguinal herniorrhaphy. Prospective analysis of 2,038 patients who underwent primary unilateral hernioplasty from 1997 to 2005 at a private university medical center. A modified technique using a mesh-plug was performed under local anesthesia with intravenous sedation. The modified technique consisted of placing the mesh plug into the preperitoneal space and suture fixation of the plug using the inner petals. The main outcome measures were Surgical morbidity, postoperative recovery, hernia recurrence, and chronic pain. There were 1,265 indirect and 773 direct hernias. Mean operative time was 28 min; mean recovery room time, 47 min. A total of 1,936 (95%) returned to normal activities within 3 days. Only 367 patients (18%) required prescription pain medication. Nine patients (0.4%) have been treated for chronic pain. No mesh infections or mesh migration have occurred. Three recurrences (0.15%) have been detected with a 99% follow-up over 2-10 years (mean 72 months). The modified mesh-plug hernioplasty is a safe and efficacious treatment option for the primary unilateral inguinal hernia patient.

Lichtenstein hernioplasty for groin hernia in central Africa

Background: Herniorraphy is a common surgical procedure in our surgical practice in Cameroon. A study was conducted in The General Hospital of Yaoundé, to assess Lichtenstein hernioplasty technique, among other hernioplasties. Materials and methods: Fourteen patients were studied, in a retrospective study of 9 years (1996 to 2005) in A General Hospital in Yaounde Cameroon, Central African. All the patients benefited from a tension-free repair using a surgical mesh of polyglactin 910 (vicril*) under local anesthesia. This technique was applied for simple inguinal hernias, bilateral hernia and recurrent hernia. Results: The time of surgery varied from 35 minutes to 140 minutes. Three complications were noted including one hematoma, one scrotal oedema and one crural neuralgia; 9 patients out of 14 were followed up closely for 9 years; no recurrence was noted. Conclusion: We therefore recommend the technique of the Lichtenstein in the repair of the groin hernia, in association to local anaesthesia in Cameroon. Keywords: groin hernia, hernioplasty, surgical mesh, Lichtenstein technique Nigerian Journal of Surgical Research Vol. 7(3&4) 2005: 315-317

Cutting the cost: Laparoscopic inguinal hernia repair by totally extraperitoneal approach without disposable instruments

Background: One of the disadvantages of laparoscopic inguinal hernioplasty by the totally extraperitoneal approach is the cost associated with disposable instrumentation that is used to establish and maintain the preperitoneal space. A prospective audit and cost‐analysis of laparoscopic inguinal hernia repair with and without disposable instruments was conducted at the Royal Hobart Hospital, Australia.Methods: The data from 94 patients undergoing laparoscopic inguinal hernioplasty (47 with and 47 without disposable instruments) were reviewed. In the group without disposable instruments, digital dissection supplemented by movements of a 30° laparoscope, and followed by dissection with laparoscopic forceps, was used instead of disposable balloon expanders to establish and maintain the preperitoneal space during hernioplasty. Detailed pre‐, intra‐, and postoperative findings were audited for each laparoscopic inguinal hernioplasty technique. In‐hospital cost analysis was conducted for theatre time, and costs of laparoscopic and disposable instruments were compared.Result: The overall cost saving of not using disposable instrumentation at the initial stage was almost $A20 000 for 47 patients (approximately $A425 per case). The difference in theatre time used was not statistically significant. In the group of hernioplasty without disposable instruments, disposable balloon expanders were still required in three patients (8.2%) due to gas leakage, and one (2.6%) required conversion to open procedure due to profuse bleeding. There were two patients in this group with postoperative complications: one with seroma and one with urinary retention.Conclusion: The preperitoneal space was established and maintained in most patients without using the specially designed balloon expanders. Therefore, this modification of the totally extraperitoneal approach could be considered safe and effective, and should be attempted initially. However, in difficult cases, the disposable balloon expanders may still be required.

Hernioplasty with bilayer polypropylene mesh: a new tension-free technique

Different open-mesh techniques have been developed for inguinal hernia repair since the introduction of the tension-free technique. The present study reports a new self-designed tension-free technique for hernioplasty using a bilayer polypropylene mesh. Fifty-one patients with severe transverse fascia weakness were repaired by means of a self-designed, tension-free technique using bilayer polypropylene mesh. The postoperative complications, inpatient hospitalization time, and recurrence rate were studied. Patients were mobilized within 6 h after surgery and no complications were found. The length of hospital stay was 2-3 days. The follow-up period ranged from 3 months to 40 months, with a mean of 20.4 months, and no recurrence was found. Our own experience showed the self-designed, tension-free technique using bilayer polypropylene mesh to be a reliable approach for inguinal hernia repair with many advantages--such as a much lower expense, simplicity, rapid return to unrestricted activities, minor complications, and impressively no recurrence, a particularly superior option for those patients with severe transverse fascia weakness or large defect.

Mechanisms of Ventral Hernia Recurrence after Mesh Repair and a New Proposed Classification

The incidence of recurrence after ventral hernia repair is prohibitive. In this article, we objectively address the reasons for the recurrence as reported in the literature andproposecorrectivemeasuresplusanewclassification of recurrence to standardize and encourage reporting. Ventral hernia repair is a commonly performed operation. In the past 4 decades, the surgical technique for ventral hernioplasty has gone through 3 stages. Before 1960, most were repaired by tissue approximation, which was accompanied by a recurrence rate of 30% to 40%. 1-4 This was noticed in particular with large defects causing the fascia to be under additional tension after closure. It became apparent that a prosthetic material was required to reinforce the repair or bridge the tissue defect. The use of a prosthetic mesh for ventral hernia repair first occurred in the early 1960s, when Usher 5,6 described the usefulness of a knitted polypropylene meshforrepairofcomplexinguinalherniasandanterior abdominal wall hernias. Prosthetic mesh improved the recurrence rate (5% to 20%), yet was associated with a higher risk of seroma, hematoma, and tissue necrosis from extensive dissection. Sitzmann and McFadden 7 reportedreductionoftherecurrencerateto2.5%whenusing internal retention sutures with mesh, and the debate about an optimal prosthetic technique of repair commenced. Laparoscopic ventral hernia repair has been recently introduced. The technique is currently popular, but the followupisinsufficienttoestablishadefinitiveappraisal. But further insight into mechanisms of recurrence may be gained by this new approach and will be included. The high recurrence rate after repair of a ventral hernia has been a concern for all surgeons experienced in this field. Ventral hernia recurrence creates morbidity, prolonged hospitalization, the need for reoperation in most circumstances, occasional mortality, and increased cost to the patient. 8 A few publications specifying a mechanismofrecurrenceemphasizefurthertheneedfor accurate reporting and careful scrutiny of patients requiring reoperation for a ventral hernia. METHODS A Medline literature review was conducted on papers in English published after 1966. The data were collected using an Excel spreadsheet and Microsoft Access database software. Exclusion criteria included: published series with less than 10 patients; series using a nonprosthetic repair; unclear descriptions of technique used; series with parastomal hernias; series with transplant patients or patients receiving peritoneal dialysis; and series withacute(traumatic)lossoftheabdominalwall.Transplant and dialysis patients were often immunosuppressed, creating an additional wound-healing variable, andpatientswithabdominalwalltraumaoftenhadmas