Incisional Hernia Patients Research Articles

Comparison of two-dimensional measurement with three-dimensional volume rendering for the assessment of loss of domain in incisional hernia patients.

We aimed to compare simple two-dimensional (2D) measurement with comprehensive three-dimensional (3D) volume rendering to determine loss of domain (LOD), a clinically important decision-making feature for incisional hernia repair. In this single-center retrospective study, we analyzed the CT scans of a consecutive cohort of adult patients with a midline incisional hernia. The hernia sac- and abdominal cavity volumes were obtained by two different methods. The 2D method estimated the volumes using the corresponding height, width, and depth. The 3D method comprised of a volume rendering tool. For both methods, LOD was calculated according to the Sabbagh ratio (hernia sac volume / (hernia sac volume + abdominal cavity volume)). Taking the 3D method as the reference standard, the performance of the 2D method was expressed as positive predictive value (PPV) and negative predictive value (NPV) for LOD of more than- and less than 20%. The agreement between both methods was expressed as Cohen's kappa coefficient (kappa). We analyzed 92 CT scans. Agreement between both methods was high (kappa = 0.854, p = 0.0001); all 67 measurements for which the 2D method assessed LOD to be less than 20% were correctly classified (NPV = 100%), and 20 of 25 measurements for which the 2D method assessed LOD to be more than 20% were correctly classified (PPV = 80%). The 2D method can exclude patients fromperioperative actions needed for a more complex hernia. Since this method is easy to use and less time-consuming, it seems useful for the routine radiological assessment of LOD in clinical practice.

A study on clinical profile and risk factors in incisional hernia patients

Incisional hernias of the abdominal wall are a frequently encountered complication in cases of open abdominal surgeries like midline laparotomies, caesarian sections etc. Wound infections, obesity, poor healing due to malnutrition etc., were thought to be the important causative factors in the development of incisional hernia.To study the clinical profile of incisional hernia patients with respect to various etiological factors, distribution of cases in relation to age and sex, details of previous surgical procedures undergone.52 patients admitted in Department of General Surgery were included in the study. Study was conducted during the period from August 2018 to August 2020 including all patient with incisional hernia. Pediatric cases were excluded from the study. Data of all the patients were collected from the hospital records and were compiled in a predesignated proforma which included patient details, clinical examination, investigations, and previous surgical history. Informed consent was obtained from each patient. Retrospective observational study. There were 32 females (61.54%) and 20 males (38.46%) with female to male ratio was found to be 1.6:1. Majority of the patients presented with abdominal swelling (n=30, 58%) followed by both abdominal swelling and pain (n=20, 38%). Among the females now presented with incisional hernias the mean parity was 2.69. Majority of the cases developed hernias within 1 year (n=29, 55.77%) and about 26.93% of the patients developed hernia in 1 to 3 years. Most of cases of incisional hernia in our study occurred over midline (n=22, 42.3%) at the site of incisions made for midline laparotomy (n=20.38.5%) Risk factors favouring incisional hernia formation were post-operative wound infection (n=45, 84.9%) and obesity (n=21, 40.38%). Incisional hernia is more common in females who undergo emergency midline laparotomy and emergency caesarean section. Majority of the cases presented within 1 year of surgery. Post-operative wound infection, obesity and anemia were the crucial factors for the development of incisional hernias.

Intramuscular Adipose Tissue Content as a Predictor of Incisional Hernia after Hepatic Resection.

Incisional hernia (IH) is a common surgical complication, with an incidence of 6-31% following major abdominal surgery. This study aimed to investigate the impact of intramuscular adipose tissue content (IMAC) on the incidence of IH in patients who underwent hepatic resection. Data of 205 patients who underwent open hepatic resection between 2007 and 2019 at Ehime University Hospital were retrospectively analyzed. Patient characteristics, perioperative findings, and body composition were compared between patients with IH and those without IH. The quantity and quality of skeletal muscle, calculated as skeletal muscle index and IMAC, were evaluated using preoperative computerized tomography images. Forty (19.5%) patients were diagnosed with IH. The cumulative incidence rates were 15.6% at 1year and 19.6% at 3years. On univariate analysis, body mass index, areas of subcutaneous and visceral fat, and IMAC were significantly higher in the IH group than in the non-IH group (p = 0.0023, 0.0070, 0.0047, and 0.0080, respectively). No significant difference in skeletal muscle index was found between the groups (p = 0.3548). The incidence of diabetes mellitus, intraoperative transfusion, and postoperative wound infection was significantly higher in the IH group than in the non-IH group (p = 0.0361, 0.0078, and 0.0299, respectively). On multivariate analysis, a high IMAC and wound infection were independent risk factors for IH (adjusted odds ratio, 2.83 and 4.52, respectively; p = 0.0152 and 0.0164, respectively). IMAC can predict the incidence of IH in patients undergoing hepatic resection.

Botulinum Toxin Use for Abdominal Wall Reconstruction

INTRODUCTION: Preoperative botulinum toxin (BTX) injection may assist in fascial closure of large incisional hernia repair. We examine outcomes of incisional hernia patients who receive BTX injections before abdominal wall reconstruction (AWR). METHODS: A retrospective cohort study of patients from 2019–2021 who underwent BTX abdominal wall injections and interval AWR was conducted. A matched cohort who underwent IH repair without BTX treatment was selected for comparable defect size and BMI. Clinical and demographic data were extracted from charts. RESULTS: Twenty patients received BTX injections, and 30 comparable patients did not. There was no difference in average age (58.6 and 61.4 years, p = 0.514), BMI (32.9kg/m2 and 32.4kg/m2, p = 0.813), or defect size (663.9 cm2 and 608.43 cm2, p = 0.513). Primary outcome of fascial closure was achieved in every patient in the BTX group (20 of 20) vs 86.7% (26 of 30) in the non-BTX group (p = 0.089). The BTX group had a lower rate of component separation (65.0% of the BTX group vs 93.3%, p = 0.01). The BTX group had higher rates of seroma (p = 0.03) and longer surgery time, 4:07 vs 3:58 (p < 0.01). The postoperative period had one dehiscence (non BTX group). There was no difference in incidence of surgical site infection, abscess, delayed healing, respiratory failure, pulmonary embolism, acute kidney injury, or length of stay. CONCLUSION: Patients receiving botulinum toxin injections into their abdominal wall musculature achieved greater rates of closure with good outcomes. We conclude that botulinum toxin injection for large incisional hernias is an effective method for relaxation of abdominal wall muscle and closure of large abdominal wall.

Tolerability of Incisional Hernia Repair Under Local Anesthesia. A Comparative Study

Introduction: Surgery under local anesthesia, a gold standard for many abdominal wall hernia, was already used for incisional hernia surgery. There are no available studies about the tolerability of this method so far. Aim of this work is to check perioperative tolerability of incisional hernia repair under local anesthesia, comparing it with local anesthesia for inguinal hernioplasty. Methods: Between 2008 and 2018 we compared tolerability of local anesthesia in 100 patients undergoing incisional hernia repair (Group A) and 100 randomized patients receiving groin hernioplasty (Group B). Selection criteria for incisional hernia patients were size of hernia defects (<10 cm), absence of obstructive symptoms, hernia reducibility. We registered referred intraoperative pain (using Visual Analogue (VAS) score: range 0-10), local anesthesia needed in ml (m.v.) for 3 solutions (A, B, C), use of intraoperative sedation, intraoperative cardiovascular alterations, early ambulation, and discharge time. Statistical comparison was made with Mann-Whitney test. Results: In Gr.A 82 patients reported no pain, 17 reported mild pain and 1 reported moderate pain vs Gr.B respectively: 51, 41 and 8. For local anesthesia solutions volume(A,B,C): in Gr.A (19.96, 44.18, 5.54 ml) vs Gr.B (19.43, 53.47, 5.72) (p>0.01, p < 0.001, p>0.5). No differences in intraoperative sedation needs or cardiovascular alterations. Conversion necessity to general anesthesia was Gr.A 2/100 vs Gr.B 0/100 (p>0.05). Postoperative early ambulation and discharge in day surgery Gr.A vs Gr.B (98/98 vs 100/100, p>0.05). Conclusion: No differences in perioperative tolerability were found between Groups. Less pain was referred in Gr.A. Local anesthesia could be proposed routinely for incisional hernia repair.

DD-04 INVESTIGATING COLLAGEN IN INCISIONAL HERNIA MIDLINE SCARS USING RAMAN SPECTROSCOPY

Abstract Aim Connective tissue alterations may lead to incisional hernia (IH) formation in a subgroup of individuals. A decreased ratio of collagen types I and III was observed in several studies. White, hard and brittle hernia scars have also been reported suggesting possible mineral deposition. These processes could affect incisional scar integrity leading to IH formation. Using advanced spectroscopy, we aim to establish whether these alterations are present in IH scars. Materials &amp; Methods Our pilot study has been granted IRAS approval and we began recruitment to investigate scar collagen in patients undergoing IH repair. We focus on the midline linea alba as the most critical layer in post-laparotomy healing and will use the participants’ fascia lata as a scar free control. Raman spectroscopy was selected to perform chemical and structural characterisation of our samples. Collagen types I, III and mineralised tissue have unique Raman spectra, which allow their identification and analysis. Results Preliminary spectral data from a porcine abdomen showed clear collagen bands in corresponding layers. We also showed mineral formation in reconstituted collagen fibres using this technique. In our pilot, Raman spectroscopy will be used to identify the bands associated with scar tissue collagen and determine differences in hernia versus hernia-free collagen. Conclusions Investigating hernia scars and the fascia lata will shed light on the local and systemic collagen changes in the scar tissue associated with IH. Raman spectroscopy provides a high-resolution insight into the composition of tissues and will identify any collagen changes in IH patients.

Visceral obesity as a risk factor of incisional hernia after single-port laparoscopic gynecologic surgery

ObjectiveWe aimed to evaluate associations between abdominal fat distribution (AFD) parameters and incisional hernia (IH) in patients who underwent transumbilical single-port laparoscopic surgery (SPLS) for gynecological disease. MethodsMedical records of 2116 patients who underwent SPLS for gynecological disease at Daejeon St. Mary's Hospital between March 2014 and February 2021 were reviewed. Among 21 (1.0%) patients who developed IH requiring surgical treatment after SPLS, 18 had preoperative abdominopelvic computed tomography (CT) images. As a control group, we randomly selected 72 patients who did not develop IH and who had undergone preoperative abdominopelvic CT scan, matched to test patients by type of surgery. Total fat area (TFA), visceral fat area (VFA), subcutaneous fat area (SFA), visceral-to-subcutaneous fat ratio (VSR), and waist circumference (WC) were measured at the level of the third lumbar vertebral body on the preoperative abdominopelvic CT images, using National Institutes of Health (NIH) ImageJ version 1.53 k. ResultsReceiver operating curve analysis showed that VFA has the highest predictive value for IH among AFD parameters (AUC = 0.749, 95% CI 0.630–0.869, p < 0.001). Univariate analysis showed that age, BMI, hypertension, dyslipidemia, TFA, VFA, VSR and WC were significant factors for IH. In multivariate analysis, only high VFA was identified as an independent risk factor for IH (HR 6.18, 95% CI 1.13–33.87, p = 0.04), whereas BMI, TFA, SFA, VSR, and WC failed to show statistical significance. ConclusionWe could find high VFA as an independent risk factor of IH in patients who underwent SPLS for gynecologic disease.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery.

To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

ETEP-RS for incisional hernias in a non-robotic center. Is laparoscopy enough to perform a durable MIS repair of the abdominal wall defect?

IntroductionIncisional hernias can complicate up to 25% of laparotomies, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced. The method was presented relatively recently and continues to evolve. The use of a robotic platform in eTEP-RS resulted in a significant improvement in ergonomics. Therefore, the questions arise as to whether the laparoscopic technique might still be feasible for such long procedures. The objective of this study is to present our early results in the treatment of patients with incisional ventral hernias using eTEP-RS and to discuss key technical aspects.Patients and methodsA prospective case-controlled study was conducted for all incisional ventral hernia patients (hernia orifice between 4 and 10 cm) who underwent eTEP-RS between March 2019 and December 2021. Demographic data were recorded; and perioperative and postoperative results were analyzed.ResultsWe performed 34 eTEP-RS procedures. The mean duration of the surgery was 211 min (145–295). The mean width of the defect was 6.8 cm and the defect area was 42.5 cm2. The mean mesh size was 498 cm2 (270–625). After an average follow-up of 16 months (2–30), there was no recurrence or major complication.ConclusionsThe eTEP-RS is a safe alternative to open ventral hernia repair in selected cases and allows for the placement of a large piece of mesh in accordance with current recommendations, even in non-robotic centers. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair. Compliance with certain rules of the laparoscopic eTEP-RS facilitates improved ergonomics for this procedure even in non-robotic centers.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: a retrospective cohort study of anastomotic complications.

Laparoscopic right hemicolectomy (LRH) can be performed with an intracorporeal anastomosis (IA) or extracorporeal anastomosis (EA). It is not clear which technique is best. This study evaluated the impact of each anastomosis technique on perioperative safety and postoperative evolution. We performed a retrospective study at a tertiary colorectal surgery center. All patients who had an elective LRH from 2015 to 2019 were analyzed according to the anastomosis technique used. In total, 285 patients were included in the study. IA was performed in 64 patients (22.5%). Mean operative time was longer in the patients with IA (IA, 160±31 minutes vs. EA, 138±42 minutes; P<0.001). No differences were observed in intraoperative complications, time to first bowel movement, length of stay, reoperation, or rehospitalization. Time to first flatus was longer in the patients with IA (P=0.049). At 30 days after surgery, there were no differences in the frequency of anastomotic leak (IA, 0% vs. EA, 2.3%; P=0.59), bleeding (IA, 3.1% vs. EA, 2.7%; P>0.99), or intraabdominal abscess (IA, 0% vs. EA, 0.5%; P>0.99). During follow-up, we noted more incisional hernias in patients with EA (IA, 1.6% vs. EA, 11.3%; P=0.01) and a trend toward more hernia in patients with EA in multivariate analysis (hazard ratio, 7.13; P=0.06). Anastomosis technique had no influence on recurrence. For LRH, both IA and EA are safe, with a low incidence of complications when performed by experienced surgeons. IA may be associated with a lower incidence of incisional hernia.

INCISIONAL HERNIA AFTER BARIATRIC SURGERY: ONLY THE PHYSICAL EXAMINATION IS ENOUGH?

ABSTRACTBACKGROUND:Incisional hernia is characterized by a bulging of the abdominal wall caused by the prolapse of intracavitary structures, such as a segment of the small intestine, through the trocar orifice. Ultrasonography and physical examination are used in the diagnosis of incisional hernia.AIMS:This study aimed to evaluate the difference between physical examination and abdominal ultrasonography at the diagnosis of incisional hernia in patients who underwent laparoscopic bariatric surgery.METHODS:A total of 123 patients who underwent Roux-en-Y gastric bypass type bariatric surgery performed by laparoscopy were analyzed for the presence or absence of hernia by physical and ultrasonography examination at each trocar incision site.RESULTS:In our results, a total of 7 hernias were detected by physical examination, while ultrasonography detected a total of 56 hernias in at least one of the incision sites. Lin's concordance analysis showed that the tests are not concordant. The association between body mass index and hernia detection (p=0.04 for physical examination and p=0.052 for ultrasonography) was observed. Ultrasonography detected more incisional hernias in 10-mm or larger trocars than in 5-mm trocars (p<0.0001, p<0.05). No differences were noted among the trocar types that were used.CONCLUSIONS:Abdominal ultrasonography showed to have a higher accuracy than physical examination, resulting in a substantial increase in incisional hernia detection at the trocar sites.

HÉRNIA INCISIONAL PRECOCE APÓS TRANSPLANTE HEPÁTICO: FATORES DE RISCO E RESULTADOS DO REPARO CIRÚRGICO

Liver transplantation is a complex and valuable therapy. However, complications that burden postoperative quality of life, such as incisional hernia, are to be better elucidated, such as risk factors and prophylactic measures. This study aimed to define the rate of incisional hernia in patients who underwent liver transplantation in a population in southern Brazil and to assess the related risk factors in order to establish measures for prior optimization and specific prophylactic care in the future. Patients undergoing adult Liver transplantation from January 2004 to November 2020 were retrospectively analyzed, assessing demographic features, surgical outcomes, and predisposing factors. Among 261 liver transplantation patients included, incisional hernia was diagnosed in 71 (27.2%). Of the 71 incisional hernia patients, 28 (39.4%) developed IH during the first post-transplant. Majority of the patients were male (52/71, 73.2%); of the 71 patients, 52 had hepatitis C virus (HCV) and 33 (46.5%) had hepatocellular carcinoma (HCC). Male gender (p=0.044), diabetes mellitus (p=0.008), and acute cellular rejection (p<0.001) were risk factors for IH. In all, 28 (39.4%) patients were submitted for hernia repair with mesh, with a recurrence rate of 17.8%. Incisional hernia after liver transplantation is a relatively common problem associated with male gender, diabetes, and acute cellular rejection. This is a problem that should not be trivialized in view of the complexity of liver transplantation, as it can lead to a reduction in quality of life as well as jeopardize late liver transplantation results and lead to incarceration and strangulation.

P057 THE ACCURACY OF INCISIONAL HERNIA CODES IN ADMINISTRATIVE DATA: A VALIDATION STUDY

Abstract Aim Administrative databases contain valuable information for studying incisional hernia (IH) following intra-abdominal procedures at a large scale. We assessed the validity of billing codes for the identification of IH in patients following abdominal surgery. Material and Methods Using International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM), a random sample of 1,000 patients who underwent abdominal operations between 2006-2020 within a large health system-wide administrative database and ≥1 year of follow-up were screened for eligibility. Validation of IH codes was performed using the electronic medical record as reference. Validity metrics of interest included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. Patient factors associated with false positive (FP) and false negative (FN) were also explored within univariate and multivariate analyses. Results 759 patients were included. The sensitivity of IH codes was 94.7% (CI 91.4 – 97.0), specificity was 94.9% (CI 92.6 – 96.7), PPV was 84.4% (CI 78.5 – 88.9), NPV was 98.4 (CI 97.4 – 99.0), accuracy was 94.9% (CI 93.0 – 96.3). Within adjusted analyses, patients admitted to a non-surgical service (relative to patients admitted to surgical services; OR 4.46 [95% CI 1.06-18.66]; p = 0.04) were associated with FP; whereas every one-year increase in age was associated with a 5.0% (95% CI 1.0%-10.0%) increase in FN (p = 0.03). Conclusions We have validated the use of ICD-9-CM and ICD-10-CM codes for accurately identifying IH following abdominal surgery. This method yields &amp;gt;94% for key validity measures.

O45 OUTCOMES OF INCISIONAL HERNIA REPAIR SURGERY AFTER MULTIPLE RE-RECURRENCES: A PROPENSITY SCORE MATCHED ANALYSIS

Abstract Aim Patients with a re-recurrent hernia may account for up to 20% of all incisional hernia (IH) patients. IH repair in this population may be complex due to an altered anatomical and biological situation as a result of previous procedures and outcomes of IH repair in this population have not been thoroughly assessed. This study aims to assess outcomes of IH repair by dedicated hernia surgeons in patients who have already had two or more re-recurrences. Material and Methods A propensity score matched analysis was performed using a registry-based, prospective cohort. Patients who underwent IH repair after ≥ 2 re-recurrences operated between 2011 and 2018 and who fulfilled 1 year follow-up visit were included. Patients with similar follow-up who underwent primary IH repair were propensity score matched (1:3) and served as control group. Patient baseline characteristics, surgical and functional outcomes were analyzed and compared between both groups. Results Seventy-three patients operated on after ≥ 2 IH re-recurrences were matched to 219 patients undergoing primary IH repair. After propensity score matching, no significant differences in patient baseline characteristics were present between groups. The incidence of re-recurrence was similar between groups (≥ 2 re-recurrences: 25% versus control 24%, p = 0.811). The incidence of complications, as well as long-term pain, was similar between both groups. Conclusions IH repair in patients who have experienced multiple re-recurrences results in outcomes comparable to patients operated for a primary IH with a similar risk profile. Further surgery in patients who have already experienced multiple hernia re-recurrences is justifiable when performed by a dedicated hernia surgeon.

Incidence and risk factors for incisional hernia after abdominal aortic aneurysm and aortic occlusive disease surgery.

Background This study aims to investigate incisional hernia incidence and risk factors after abdominal aortic aneurysm and aortic occlusive disease surgery via a midline laparotomy. Methods A total of 110 patients (66 males, 44 females; mean age: 69.3±8.8 years; range, 36 to 88 years) who underwent open elective surgery for aortoiliac occlusive diseases or abdominal aortic aneurysm between January 2005 and December 2016 were retrospectively analyzed. Both patient groups were compared in terms of surgical procedures, sex, age, American Society o f A nesthesiologists s core ( 1-3), b ody m ass i ndex (<25 vs. ≥25 kg/m2), smoking (non-smoker <1 pack/day, smoking ≥1 pack/day), and time to incisional hernia development. Results Incisional hernia occurred in 14.3% of the patients operated for aortoiliac occlusive disease and in 17.6% of the patients operated for abdominal aortic aneurysm (p=0.643). Incisional hernia was seen in three (5.7%) of 53 patients with a body mass index of <25 kg/m2 and was in 15 (26.3%) of 57 patients with a body mass index of ≥25 kg/m2 (p=0.03). Conclusion High body mass index is a risk factor for incisional hernia in patients undergoing aortic reconstructive surgery.

To Study the Repair of Incisional Hernia by Preperitoneal Meshplasty

The preperitoneal mesh repair an excellent method called as Rive’s stoppa technique where mesh was placedbetween peritoneum and abdominal wall or rectus muscle and posterior rectus sheath(9). The main advantageof pre peritoneal mesh repair are - Less chance of mesh infection and erosion through skin because thegraft lies in preperitoneal plane between posterior rectus sheath and peritoneum, avoids adhesions, bowelobstruction, enterocutaneous fistula and erosion of mesh, minimal morbidity and duration of hospitalstay is less compared to other techniques. The main disadvantage is it is more time consuming, extensivepreparation of preperitoneal plane and surgical experience. In our study 30 patients of incisional hernia weresubjected to preperitoneal mesh repair by Rive’s stoppa technique.It was found that there were :1. Less number of postoperative complications.2. No recurrence was noticed in this study.3. Preperitoneal mesh repair had excellent long-term results with minimal morbidity.As Compared withother types of mesh repair techniques (in literature), the preperitoneal mesh repair is the gold standardtreatment for incisional hernia repair.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined. This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations. From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P < 0.001). One patient in the mesh group required mesh removal because of deep infection. Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

Peritoneal flap hernioplasty for repair of incisional hernias after orthotopic liver transplantation

BackgroundRepair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in the context of lifelong immunosuppression. The peritoneal flap hernioplasty addresses this problem by using flaps of the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space, exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. We report our short and long-term results of 26 consecutive liver transplant cases with incisional hernias undergoing repair with the peritoneal flap technique.MethodsPost-OLT patients undergoing elective peritoneal flap hernioplasty for incisional hernias from Jan 1, 2010–Nov 1, 2017 were identified from the Lothian Surgical Audit system (LSA), a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in Feb 2020.ResultsA total of 517 liver transplantations were performed during the inclusion period. Twenty-six of these (18 males, 69%) developed an incisional hernia and underwent a peritoneal flap repair. Median mesh size (Optilene Elastic, 48 g/m2, BBraun) was 900 cm2 (range 225–1500 cm2). The median time to repair following OLT was 33 months (range 12–70 months). Median follow-up was 54 months (range 24–115 months) and median postoperative stay was 5 days (range 3–11 days). Altogether, three patients (12%) presented with postoperative complications: 1 with hematoma (4%) and two with chronic pain (8%). No episodes of infection or symptomatic seroma were recorded. No recurrence was recorded within the follow-up period.ConclusionRepair of incisional hernias in patients following liver transplantation with the Peritoneal Flap Hernioplasty is a safe procedure associated with few complications and a very low recurrence rate. We propose this technique for the reconstruction of incisional hernias following liver transplantation.

Chemotherapy and Abdominal Wall Closure Technique Increase the Probability of Postoperative Ventral Incisional Hernia in Patients With Colon Cancer.

Chemotherapy is associated with postoperative ventral incisional hernia (PVIH) after right hemicolectomy (RHC) for colon cancer, and abdominal wall closure technique may affect PVIH. We sought to identify clinical predictors of PVIH. We retrospectively analyzed patients who underwent RHC for colon cancer from 2008-2018 and later developed PVIH. Time to PVIH was analyzed with Kaplan-Meier analysis, clinical predictors were identified with multivariable Cox proportional hazards modeling, and the probability of PVIH given chemotherapy and the suture technique was estimated with Bayesian analysis. We identified 399 patients (209 no adjuvant chemotherapy and 190 adjuvant chemotherapy), with an overall PVIH rate of 38%. The 5-year PVIH rate was 55% for adjuvant chemotherapy, compared with 38% for none (log-rank P < .05). Adjuvant chemotherapy (hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.18-2.31, P < .01), age (HR .99, 95% CI .97-1.00, P < .01), body mass index (HR 1.02, 95% CI 1.00-1.04, P < .01), and neoadjuvant chemotherapy (HR 1.92, 95% CI 1.21-3.00, P < .01) were independently associated with PVIH. Postoperative ventral incisional hernia was more common overall in patients who received adjuvant chemotherapy (46% compared with 30%, P < .01). In patients who received adjuvant chemotherapy, the probability of PVIH for incision closure with #1 running looped polydioxanone was 42%, compared with 59% for incision closure with #0 single interrupted polyglactin 910. Exposure to chemotherapy increases the probability of PVIH after RHC, and non-short stitch incision closure further increases this probability, more so than age or body mass index. The suture technique deserves further study as a modifiable factor in this high-risk population.

Length of stay and surgical site complications are not increased after elective incisional hernia in patients with a history of solid organ transplantation.

The incidence of ventral hernia development after solid organ transplantation has been reported to be up to 30%. We aim to determine the impact of previous solid organ transplant on post-operative length of stay (LOS) and surgical site complications in elective ventral hernia repairs. A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was conducted to include all patients age 18years or older who underwent elective incisional hernia repair. Those with and without a history of solid organ transplantation were compared. The primary outcome was in-hospital LOS. Secondary outcomes included 30-day surgical site infection (SSI) rate, 30-day surgical site occurrence requiring procedural intervention (SSOPI) rate, 30-day overall post-operative complications and recurrence. The association between transplant and the LOS was tested with a negative binomial regression model adjusted for the demographic characteristics, comorbidities and hernia characteristics in the model. The population analyzed included 13,452 (98.79%) patients without a history of organ transplantation and 165 (1.21%) patients who had a history of organ transplantation. After adjusting for age, hernia width, BMI, gender, race, insurance type, ASA class, hypertension, dyspnea, OR time > 2h, abdominal wall SSI history, recurrent hernia, operative approach the median LOS was not significantly different between patients with a history of solid organ transplant [2.8 (2.6, 2.9) days] and those without [2.6days (2.2, 3.1)] (p = 0.5). The proportion of SSI (2.4% vs 4.04%; p = 0.42), SSOPI (4.2% vs 5.8%; p = 0.38) and recurrence (0.6% vs 0.4%, p = 0.51) was similar between both groups. Other remaining 30-day post-operative were negligible in our sample. There were no significant differences in LOS or infection rates between patients with and without a history of solid organ transplantation despite known risks of immunosuppression and chronic steroid use. Therefore, although these patients have many classic risk factors for poor outcomes, the data suggest that their history of solid organ transplantation should not preclude them from surgery.