Large Ventral Hernias Research Articles

EVOLUTION OF COMPONENT SEPARATION TECHNIQUE (REVIEW)

The problem of treatment of incisional ventral hernias is currently very relevant. The appearance of a hernial defect in the area of a previous operation is one of the most frequent long-term complications of any surgical treatment. Component separation techniques are the most modern and promising methods for the treatment of large ventral hernias. The review focuses on the main stages in the development of separation technique, as well as the results of treating patients with incisional ventral hernias using various options for posterior separation repair, which are currently frequently used. It has been established that posterior component separation is an effective and safe method of treatment, however, there is currently insufficient data on the long-term postoperative period and patients quality of life.

Abdominoplasty Combined with the Anterior Component Separation Technique for Reconstruction of Midline Large Ventral Hernias: Functional and Aesthetic Outcome Clinical Study

Abdominoplasty Combined with the Anterior Component Separation Technique for Reconstruction of Midline Large Ventral Hernias: Functional and Aesthetic Outcome Clinical Study

Abdominoplasty combined with the anterior component separation technique for reconstruction of midline large ventral hernias: functional and aesthetic outcome clinical study

Abdominoplasty combined with the anterior component separation technique for reconstruction of midline large ventral hernias: functional and aesthetic outcome clinical study

Giant ventral hernia following left ventricular assist device bridge to heart transplantation.

Ventral hernias following left ventricular assist device (LVAD) placement are rare. With the improvement in technology, and miniaturization of devices associated with intrapericardial placement, these complications have largely been abolished. The mere presence of a large ventral hernia should not exclude recipients from being candidates for orthotopic heart transplantation.

A New Method of Tension-Free Plasty of Giant and Large Postoperative Ventral Hernias Using a Hernia Sac

We planned to develop a tension-free hernioplasty method for giant and large postoperative ventral hernias. Twenty-three patients with complicated postoperative ventral hernias were operated on using the method. Ultrasound, computed tomography, and plain radiography of the abdominal organs were performed for diagnosis.We have developed a tension-free hernioplasty method, where we placed a mesh implant between the fl aps of the hernial sac in order to isolate it from the abdominal organs and subcutaneous fat. When applying this method, positive results were obtained (this method is absolutely tension-free plasty of the anterior abdominal wall, since own tissues are not put together; the location of the mesh implant made it possible to signifi cantly reduce or almost completely avoid local complications, such as seroma, suppuration of the postoperative wound, fi stula formation.This method can signifi cantly reduce the percentage of local complications and completely avoid compartment syndrome in the early postoperative period. In all patients operated on by the method, no relapses were observed during the follow-up period (3 years).

Peritoneal sandwich technique: a novel technique in the treatment of large ventral hernias

No abstract available

Bridged repair of large ventral hernia defects using an ovine reinforced biologic: A case series

IntroductionOf all hernia types, large ventral hernias have the most impact on patient quality of life, however they are also the most difficult type of hernia to repair and are associated with high rates of complications. This case series describes repair of large ventral hernias with an ovine reinforced biologic in a complex patient cohort with comorbidities and concomitant procedures. MethodsThe author performed bridged repair with an ovine reinforced biologic in 19 consecutive high-risk patients over a 5-year period. In all cases the reinforced biologic was used as an underlay. OutcomesOf the 19 patients, six (32%) experienced a surgical site occurrence including infection, seroma, abscess, fistula, bioloma, or bowel obstruction. Three patients (16%) had recurrences with two out of three of the recurrences occurring within 6 months of surgery. ConclusionsRates of SSO's and recurrences using ovine reinforced tissue matrix (RTM) were in line with or better than other published studies of bridged repair utilizing biologic or synthetic mesh reinforcement. Ovine RTM's should therefore be considered in complex large ventral hernia repairs.

Management of a Voluminous Incisional Hernia – Case Report and Brief Review

Abstract Introduction: Massive ventral hernia repairs may lead to abdominal compartment syndrome, which is associated with increased morbidity and mortality, and is caused by an acute rise in intra-abdominal pressure, frequently leading to multi-organ failure and possibly death. This report presents a case with a voluminous incisional hernia associated with intestine obstruction and the issues surrounding emergency surgical treatment. Case report: An overweight 67-year-old patient with a medical history of diabetes and multiple cardiovascular pathologies presented to the emergency department complaining of abdominal distension, pain, nausea, vomiting, and lack of intestinal transit for 48 hours. A clinical diagnosis of bowel obstruction was established, caused by a large ventral hernia. During surgery, a tension free abdominal wall reconstruction was performed with a peritoneal flap from the hernia sac and retromuscular Prolene synthetic mesh. A Redon-type drainage of the posterior rectus compartment and subcutis was applied for 48 hours. After the operation, the patient was transferred to the intensive care unit for monitoring. During the follow-up, continuous monitoring of arterial blood pressure, oxygen saturation, renal function, daily diuresis, lactic acid values, and intraabdominal pressure was performed. On the 9th postoperative day, the patient was released in good general health, stable from a cardiorespiratory point of view, with a clean, healing surgical wound. Conclusion: The repair of large ventral hernias is technically challenging. The management of giant incisional hernias is complex, requiring thoughtful preoperative evaluation with CT imaging and volumetry calculation, which can help establish the surgical strategy.

A retrospective comparison of outcomes after open anterior and posterior component separation by a single surgical team.

While both anterior and posterior component separation techniques aid the repair of large ventral hernias, their outcomes can be remarkably dissimilar in terms of wound morbidity. We describe outcomes after open component separation by a single surgical team over the entire breadth of our experience. We queried a prospectively maintained database for ventral hernias who received an open bilateral component separation between January 2014 and January 2020. A retrospective review was performed to analyze patient demographics, perioperative events, adverse outcomes, and recurrence. One hundred twenty-seven patients met the inclusion criteria of which 44 underwent anterior component separation (ACS) and 83 underwent posterior component separation (PCS). The two groups were broadly similar in terms of demographic and hernia-related variables. Mesh:defect area ratios, operative time, and estimated intraoperative blood loss were higher in the PCS group. The ACS group had more frequent use of drains which remained in situ for longer, along with a longer hospital stay. Surgical site occurrences (SSOs), including those needing procedural intervention (SSOPIs) were significantly more common after ACS. This group was also more likely to undergo a reoperation within 30days of index repair. A single recurrence was noted in the ACS group after a mean follow-up duration of 43months. Open PCS may be more technically demanding than ACS, but it has a lower risk of postoperative morbidity and reoperation. While we now utilize PCS more frequently in our practice, ACS remains an important tool in our armamentarium.

Expanding your surgical tools for large ventral and incisonal hernias

Expanding your surgical tools for large ventral and incisonal hernias

Robotic transversus abdominis release for ventral hernia repairs

Background: Robotic transversus abdominis release (roboTAR) is a minimally invasive surgical approach for ventral hernia repairs that builds on the concepts developed by Rives and Stoppa. The Rives–Stoppa procedure incorporates Rives’ retromuscular repair and Stoppa’s concept of giant prosthetic reinforcement of the visceral sac (GPRVS).[1] In an effort to mitigate the limitations of the Rives–Stoppa procedure, Novitsky et al. developed the open transversus abdominis release (TAR). The TAR approach is favorable when repairing large ventral hernia defects, as it provides myofascial advancement to reconstitute linea alba, preserves the neurovascular bundles of the medial abdominal wall, and creates a large extraperitoneal space to allow for mesh reinforcement. Methods: The three main technical components of the roboTAR include the following: bottom-up, Novitsky method, and top-down approach. An understanding of the anatomy and technique involved in the three techniques is critical for performing roboTAR. Results: Within the authors’ practice, the average hernia defect size is 115 cm2. With a n = 200, approximately 1% of our patients has had a surgical site complication. Recurrences are rare and occur in very large complex hernias. The average operative time is approximately 400 min with an average length of stay being 1.2 days. This is consistent with others. Conclusion: Utilizing a minimally invasive approach, as seen in roboTAR, provides additional advantages, including shorter length of hospital stay, reduced wound morbidity, reduced postoperative pain, and expedited return to work and activities of daily living. This article is a comprehensive review of the pertinent anatomy, preoperative evaluation, operative technique, and the postoperative course of roboTAR.

P023 MANAGEMENT OF MASSIVE INCISIONAL HERNIA WITH LOSS OF DOMAIN

Abstract Aim Large incisional hernia treatment is challenging for surgeons especially when there is loss of domain. Its management require an appropiate preoperative optimization of the patient. We present a complex case that provides an exhaustive review of different measures in order to treat this type of hernias. Material and Methods A 61-year-old, smoker and diabetic patient consulted because of a large ventral hernia. He underwent an umbilical hernia surgery which recurred three more times. The patient had a M1-M5 W3 hernia with active suppuration through fistulous orifices. The abdominal wall planning CT scan showed a large eventration with 23 cm of transverse defect diameter and a Tanaka index of 92%. Results The patient received support to quit smoking and he lost weight due to an intragastric balloon. Botulinum toxin was administered six weeks before surgical intervention. An andominal pneumeperitoneum catheter was placed, reaching 12.400 liters of ambient air insufflated during 13 days. Finally, surgery was performed, finding a 27 x 35 cm wall defect that required the performance of: After these maneuvers, the posterior abdominal wall could be completely closed. A double preperitoneal mesh (BioA and polypropylene) was placed. After 16 days, he was discharged without mayor complications. Conclusions Loss of domain hernias are a complex entity which requires a multidisciplinary approach and abdominal wall experienced surgeons since it may require extreme measures.

Acute Kidney Injury After Large Ventral Hernia Repair Requiring Transversus Abdominis Release.

Acute kidney injury (AKI) is a known postoperative complication of open ventral hernia repair contributing to increased costs, hospital length of stay, and mortality. The aim of this study was to identify whether the muscle injury that occurs in a posterior separation of components via transversus abdominis release (TAR) contributes to a higher incidence of postoperative AKI. A retrospective cohort study of patients who underwent open retrorectus ventral hernia repair with and without TAR at a single institution between 2012 and 2019 was performed. Patients who underwent a separation of components via either unilateral or bilateral transversus abdominis release were compared to those who did not undergo TAR as part of their hernia repair (non-TAR). The outcome of interest was the development of postoperative AKI. Acute kidney injury was defined as an increase in creatinine of greater than 50% of the preoperative baseline. Univariate and multivariate analyses were performed to determine the influence of TAR on the development of AKI. There were 523 patients who met inclusion criteria, of which 159 (30.4%) had a TAR as part of their retrorectus hernia repair. No differences were found in preoperative characteristics between the TAR and non-TAR group including age, gender, history of kidney disease, or history of diabetes. By contrast, the TAR group had significantly greater median estimated blood loss (100mL vs 75mL, P < .01), mean positive intraoperative fluid balance (2255mL vs 1887mL, P < .01), and operative duration (321min vs 269min, P < .001). The rate of AKI in the TAR group was 11% (n = 18) vs 6% (n = 23, P = .0503) in the non-TAR group. On multivariate analysis controlling for patient characteristics and intraoperative factors, TAR was the only factor with a significantly increased odds of AKI (OR 1.97, 95% CI 0.994-3.905, P = .0521). In patients with large ventral hernias requiring retrorectus repair, performing a TAR is associated with a nearly 2-fold increase in the development of postoperative AKI. These findings suggest that these patients should be optimized perioperatively with emphasis on fluid resuscitation, limiting nephrotoxic medications and monitoring urine output.

Preoperative Progressive Pneumoperitoneum Revisited.

Incisional hernia represents a common and potentially serious complication of open abdominal surgery, with up to 20% of all patients undergoing laparotomy subsequently developing an incisional hernia. This incidence increases to as much as 35% for laparotomies performed in high-risk patients and emergency procedures. A rarely used technique for enabling closure of large ventral hernias with loss of domain is preoperative progressive pneumoperitoneum (PPP), which uses intermittent insufflation to gradually stretch the contracted abdominal wall muscles, increasing the capacity of the abdominal cavity and allowing viscera to re-establish right of domain. This assists in tension-free closure of giant hernias which may otherwise be considered inoperable. This technique may be used on its own, or in conjunction with preoperative Botulinum Toxin A to confer paralysis to the lateral oblique muscles. These two complementary techniques, are changing the way complex hernias are managed.

Laparoscopic ventral hernia repair: does IPOM plus allow to increase the indications in larger defects?

The laparoscopic ventral hernia repair (LVHR) may have a limit of effectiveness, especially in defects greater than 80cm2, with a higher recurrence rate which contraindicates this technique. The purpose of this study is to analyze the indication of LVHR determining and comparing the recurrence rate according to defect size in two series. We analyzed all patients who underwent LVHR between 2007 and 2017. Patients were divided according to the ring size: < o ≥ 80cm2 into group one (G1) and group two (G2) respectively. In both groups, all three techniques were used: intraperitoneal onlay mesh (IPOM), IPOM with closure of the defect (IPOM plus), and IPOM plus + anterior videoscopic component separation (AVCS). A total of 258 patients underwent LVHR. Mean recurrence rate was 13% in G1 and 24% in G2. A statistically significant difference was found when comparing the IPOM technique among both groups, with a higher recurrence rate when ring size was ≥ 80cm2 (p < 0.5). However, when comparing recurrence rate in IPOM plus and IPOM plus + AVCS between both groups, no significant differences were observed, yielding a p of 0.51 and 0.63, respectively. The IPOM technique has shown a limit of effectiveness in large ventral hernia defects. The combination of techniques (ring closure and AVCS) may be useful to expand the indication for this surgery to larger defects and to reduce the recurrence rate. Prospective randomized studies are required to confirm this trend.

A SERENDIPITOUS DETOUR: DIRECT PERCUTANEOUS EMBOLIZATION OF ECTOPIC VARIX

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Variceal bleeding can be a devastating complication of cirrhosis; a minority of varices develop at sites apart from the esophagus or the stomach. We present the case of an ectopic variceal bleeding complicated by hemorrhagic shock, managed by direct percutaneous embolization of an ectopic small bowel varix in a ventral hernia. CASE PRESENTATION: A 47-year-old woman with a history of decompensated alcoholic cirrhosis presented with sudden onset profuse bright red bloody output per rectum. She was hypotensive, tachycardic, and had a ventral hernia. Labwork was notable for anemia (hemoglobin 2.9 mg/dL). Computed tomography (CT) angiography of the abdomen and pelvis did not reveal a source of hemorrhage, but did show a large ventral hernia containing small bowel without signs of strangulation. She was treated with pantoprazole, octreotide, transfusions of packed red cells and fresh frozen plasma, vasopressor support, and mechanical ventilation. Esophagoduodenoscopy revealed mild non-bleeding esophageal varices. Colonoscopy revealed a few mild oozing sites of portal colopathy treated with cautery. Given the presence of chronic portal vein thrombus and extensive collaterals, there was concern for a small bowel ectopic varix. On review of initial imaging, a dilated varix was noted to track along a loop of small intestine in the ventral hernia. She underwent percutaneous puncture of the ectopic varix under ultrasound guidance, followed by extensive coiling and gel foaming of the superior mesenteric venous system. Following the procedure, the patient developed gastrointestinal bleeding necessitating massive transfusion. Repeat esophagoduodenoscopy demonstrated grade II esophageal varices with active bleeding treated with banding. Continued hemorrhage led to hemodynamic collapse, followed by the patient's demise. DISCUSSION: Small bowel varices can be challenging to diagnose; they may be treated with transjugular intrahepatic porto-systemic shunt (TIPS), enteroscopy, embolization, or surgery. Percutaneous embolization was chosen as the treatment modality in our patient due to profound hemodynamic instability and emergent need for homeostasis. This is usually carried out via a transjugular, transfemoral, or transhepatic approach. The serendipitous presence of a portion of the ectopic varix on a loop of small bowel in a ventral hernia afforded the unconventional approach employed here. There have only been a few cases managed via a similar approach based on our literature review. Embolization was carried out successfully, but was complicated by bleeding from other varices, perhaps due to increased pressure in the portal venous system. CONCLUSIONS: Direct percutaneous varix embolization may be employed in the critical care setting provided favorable anatomy is present. REFERENCE #1: Lim L, Lee Y, Tan L, et al. Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices. World J Gastroenterol. 2009 Aug 14; 15(30): 3823–3826. DISCLOSURES: No relevant relationships by Ajinkya Buradkar, source=Web Response no disclosure on file for William Haas; No relevant relationships by Danish Haque, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response no disclosure on file for Nikul Patel; No relevant relationships by Arooj Quadir, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response

Large ventral hernias: to drain… And what to drain… That is the question!

Drain placement is common practice in repair of ventral hernias, specifically complex hernias. There is little-to-no evidence for benefit of drains and best practice in-terms of number, position, duration of use and type of drains. This study investigates drain profile in open repair of large ventral hernias. A retrospective two-centres audit with data collected via electronic and paper-based medical records from the 1 February 2015 to 29 June 2020. All elective and emergency cases were included. Main outcomes included surgical site infection (SSI), seroma and hematoma formation. A total of 186 patients included, out of those 128(68.5%) had drain placed. Drain placement had a higher incidence of SSI (20.3% in drain group and 15.5% in no drain group), however, drains were more likely to be placed in complex ventral hernias. Drain practice varied significantly between surgeons, however, there was a clear trend to higher SSI rates with longer duration of drain use (specifically longer than 5 days, p-value: 0.05) and higher drain output on removal (specifically higher than 150 ml/24 h, p-value 0.004), furthermore, prolonged use did not decrease risk of seroma formation. Drain position, number of drains and suction pressure did not affect seroma or SSI rates. Our data suggests no clear benefits of drain usage in most ventral hernia repairs. Prolonged drain use led to higher risk of SSI and did not decrease rate of seroma formation. If used, we recommend use of short drain duration<5 days. Further RCTs to evaluate drain placement in large ventral hernias are needed.

Greatest Quality of Life Improvement in Patients With Large Ventral Hernias: An Individual Assessment of Items in the HerQLes Survey

Ventral hernia repair (VHR) has been shown to improve overall quality of life (QOL) by the validated 12-question Hernia-Related Quality-of-Life survey (HerQLes). However, which specific aspects of quality of life are most affected by VHR have not been formally investigated. Through retrospective analysis of the Abdominal Core Health Quality Collaborative national database, we measured the change in each individual component of the HerQLes questionnaire from a pre-operative baseline assessment to one-year postoperatively in VHR patients. In total, 1,875 VHR patients had completed both pre- and post-operative questionnaires from 2014-2018. They were predominately Caucasian (92.3%), 57.9 ± 12.4 Y old, and evenly gender split (50.5% male, 49.5% female, P=0.31).Most operations were performed open (80.5%) with fewer laparoscopic (7.5%) or robotic cases (12.1%). For each of the 12 individual categories, improvement in QOL from baseline to 1-Y was found to be statistically significant (P < 0.0001). This held true with subgroup analysis of small (<2 cm), medium (2-6 cm), and large (>6 cm) hernias (P < 0.0001), though a larger improvement was seen in 8 of 12 components in hernias >6 cm (P < 0.001). Operative approach did not carry a significant effect except in medium hernias (2-6 cm), where an open approach saw a greater improvement in the "accomplish less at work" item (P=0.02). VHR is associated with improvement in each of the 12 components of QOL measured in the HerQLes questionnaire, regardless of the size of their hernia. The amount of improvement, however, may be dependent on hernia size and approach.

Single institute experiences in anterior and posterior component separation technique for the large ventral hernia: A retrospective review

BackgroundComponent separation techniques have recently gained popularity for the repair of complex ventral hernias. Anterior and posterior component separation techniques offer similar myofascial medialization, with a differing complication profile. The aim of this study is to compare the efficacy, patient morbidity and post-operative complications between anterior component separation (ACST) and transversus abdominis release (TAR) for large ventral hernias. MethodsBetween December 2017 and September 2019, data was collected and analysed for patients undergoing ACST and TAR, in terms of demographics, peri-operative events, adverse events and hernia recurrence. Results25 patients each underwent ACST and TAR during our study period. Mean age was 53.5 and 52.8 years and mean BMI was 31.4 and 29.5 respectively. The mean defect area was 120.8 cm2 and 131.9 cm2, and average mesh size was 741.8 cm2 and 1429.04 cm2 respectively in the ACST and TAR groups. Four patients undergoing TAR had intra-operative complications with none in the ACST group. In the ACST group, 8 patients had an SSI, of which 5 patients needed operative intervention, while 3 patients in the TAR group had an SSI, all of whom were managed with bedside procedures. One patient in the ACST group had a recurrence. None of the patients in the TAR group had a recurrence. ConclusionsComponent separation techniques are gaining popularity in treatment of large ventral hernias. While they have comparable outcomes with respect to recurrence, wound morbidity is more frequent and severe in the ACST group.

Evaluation of outcomes of 5cm all-around mesh reinforcement after endoscopic component separation and midline closure during laparoscopic ventral hernia repair

Background: To evaluate the short term recurrence, pain scores, infection rates and cost factors by using 5cm all around composite mesh reinforcement of the closed defect after endoscopic video-assisted component separation for large ventral hernia repair. Methods: All patients who were clinically assessed to have large (≥5cm diameter of defect) midline ventral hernia underwent an abdominal CT as per protocol to calculate the Component Separation Index and were subjected to endoscopic video-assisted component separation. Next laparoscopy is done, hernial contents were reduced with adhesiolysis and midline defect is closed vertically with VLoc sutures, under physiologic tension. The closed suture line is reinforced with a mesh having a 5cm all round overlap irrespective of the original hernia defect. Results: A total of 30 patients were operated. Over a follow up period ranging from 3-18 months there were no recurrences, no surgical site infection, no seroma formation, no mesh infection, fewer tackers were required resulting in more favorable pain scores. Due to smaller mesh and fewer tackers there was significant cost reduction per case. Conclusion: Endoscopic component separation technique is useful in tension less large midline ventral hernia repair. Only 5cm all around mesh reinforcement of midline closure is required thus significantly cutting down the cost of surgery with excellent patient outcome.