Management Of Abdominal Wall Hernias Research Articles

ROBOT-ASSISTED EXTRAPERITONEAL VENTRAL HERNIA REPAIR—EXPERIENCE FROM THE FIRST 160 CONSECUTIVE OPERATIONS WITH LATERAL eTEP AND eTAR TECHNIQUES

Abstract Background As in various other surgical domains, robotically assisted procedures have become integral in the management of ventral hernias in recent years. The employment of robotic technology enables the integration of minimally invasive techniques with retromuscular mesh placement. Beyond the conventional transabdominal approach, these surgical interventions can alternatively be executed in a total extraperitoneal fashion. The objective of this study is to demonstrate that robotic total extraperitoneal management of abdominal wall hernias is safe and efficient. Method A retrospective analysis encompassing all patients who underwent robotic surgery for ventral hernia repair utilizing the extraperitoneal eTEP technique with a lateral approach was conducted. The study period spanned from December 2019 to December 2023. Results Over the study period, a total of 160 patients underwent surgical intervention utilizing the lateral robotic eTEP technique. Among these cases, 43 patients required a lateral extension of retro-rectal dissection through extraperitoneal transversus abdominis release (eTAR) due to either the hernia size or lateral hernia localization. In every instance, an uncoated synthetic mesh was positioned in the retromuscular location, accompanied by complete fascial closure. The median hernia defect area was 25 cm² (2.25–375 cm²). The median mesh size was 540 cm² (225–1350 cm²). The median mesh defect ratio (MDR) was 21 (2.3–150). Two conversions (1.72%) were necessary. One intraoperative and seven postoperative complications were encountered (5%) out of which two required reoperations (1.72%). Conclusion The robotic extraperitoneal eTEP technique enables a retromuscular mesh placement in a minimally invasive approach. With the possibility of combination with a transversus abdominis release, even complex findings can be treated using this technique.

OC-094 LESSONS LEARNT FROM DEVELOPING AN ABDOMINAL WALL RECONSTRUCTION (AWR) MULTIDISCIPLINARY TEAM (MDT) IN A COMPREHENSIVE HERNIA CENTRE

Abstract We present our experience of developing a successful AWR MDT in a Tertiary Referral Centre, which aimed to optimise the management of complex AWR patients. The weekly AWR MDT was established in August 2020. Cases are discussed with a hollistic approach. A comprehensive individualised plan is agreed regarding appropriateness of surgery, pre-operative risk factors requiring optimisation and operative specific decisions. 151 patients have been discussed to date (118 incisional hernias, 33 primary). In 65% of patients, at least one risk factor for adverse surgical outcomes was identified that required pre-optimisation, most commonly the need for weight loss (93%), glycemic control (22%), & smoking cessation (22%). 50 patients have been operated on to date. Retrorectus repair was the most commonly used technique (86%). Adjuvant techniques such as peritoneal flaps were suggested in 36% of patients. 23 patients are currently on waiting list for surgery, 45 remain in their prehabilitation period. 20 patients did not undergo surgery after combined patient and MDT decision. 8 patients await further investigation and 5 patients have been transferred to other centres due to specialist input requirement. MDT management of abdominal wall hernias remains poorly established in most regions. Our experience highlights how vital it is. We have proven that it is feasible to run MDTs and that it has improved pre-operative planning and focus on modifiable risk factors in our centre. We would encourage other centres to establish this for complex cases, so that the most appropriate decisions can be made for this surgically challenging group.

LAPAROSCOPIC MESH EXPLANTATION FOR MESH INFECTIONS FOLLOWING INTRA PERITONEAL ON-LAY MESHPLASTY (IPOM): A CASE SERIES

The introduction of synthetic mesh has become the standard of care in the management of abdominal wall hernias [1,2]. However, the slightest of breach in the sterility chain can lead to mesh infection and biolm formation which often requires a prolonged stay in hospital with long term use of antibiotics and need for multiple interventions. Incidence of mesh infection is dependent on both Intra-operative events as well as pre-existing modiable risk factors in the patient. Mesh infection can present as abscess, chronic discharging sinus and sepsis [1] However, in most cases, mesh explantation is required. In this paper, we present a series of 5 patients who underwent laparoscopic mesh explantation following IPOM mesh infection with good outcomes.

Robot-assisted extraperitoneal ventral hernia repair-Experience from the first 61 consecutive operations with eTEP and eTAR techniques

As in many other fields of surgery, robotically assisted surgical procedures have been established in the treatment of ventral hernias in recent years. The use of the robot can combine the demands of a minimally invasive approach and retromuscular mesh placement. In addition to a transabdominal approach, these procedures can also be performed using an extraperitoneal approach. The purpose of this study is to demonstrate that robotic total extraperitoneal management of abdominal wall hernias is safe and efficient. A retrospective analysis of all robotically operated patients on ventral hernia using extraperitoneal eTEP technique from September 2019 to May 2022 was performed. A total of 61 ventral hernias were operated on using the robotic eTEP technique during the study period. In 14 patients retro-rectal dissection was extended laterally by an extraperitoneal transversus abdominis release (eTAR) because of the hernia size or a lateral hernia localization. In all cases, an uncoated synthetic mesh was placed in the retromuscular position with complete closure of the hernia defects. The median hernia defect area was 30 cm² (4-308 cm²). The median mesh size was 540 cm² (300-1350 cm²). The median mesh defect ratio (MDR) was 17.78 (3.06-145). One intraoperative and three postoperative complications were encountered. Neither conversion nor reoperation were required. The robotic extraperitoneal eTEP technique enables the required retromuscular mesh placement in a minimally invasive approach. With the possibility of a combination with a transversus abdominis release, even complex findings can be treated using this technique.

Exploration of Surgeon Motivations in Management of Abdominal Wall Hernias

Although evidence-based guidelines designed to minimize health care variation and promote effective care are widely accepted, creating guidelines alone does not often lead to the desired practice change. Such knowledge-to-practice gaps are well-recognized in the management of patients with abdominal wall hernia, where wide variation in patient selection and operative approach likely contributes to suboptimal patient outcomes. To create sustainable, scalable, and widespread adherence to evidence-based guidelines, it is imperative to better understand individual surgeon motivations and behaviors associated with surgical decision-making. To evaluate the systematic application of the Theoretical Domains Framework (TDF) to explore motivations and behaviors associated with surgical decision-making in abdominal wall hernia practice to help inform the future design of theory-based interventions for desired practice and behavior change. This qualitative study used purposive sampling to recruit 21 practicing surgeons at community and academic hospitals from 5 health regions across Michigan. It used interviews consisting of clinical vignettes for highly controversial situations in abdominal wall hernia repair, followed by semistructured interview questions based on the domains of the TDF to gain nuance into motivating factors associated with surgical practice. Patterns within the data were located, analyzed, and identified through thematic analysis using software. All data were collected between May and July 2018, and data analysis was performed from August 2018 to July 2019. Factors associated with decisions on the surgical approach to abdominal wall hernia repair were assessed using TDF. Seventeen (81%) of the 21 participants were men, with a median (interquartile range) age of 47 (45-54) years. Of the 14 TDF domains, 5 were found to be most associated with decisions on the surgical approach to abdominal wall hernia repair for surgeons in Michigan: knowledge, beliefs about consequences, social or professional role and identity, environmental context and resources, and social influences. Mapping of the findings to the sources of behavior identified the potential intervention functions and policy categories that could be targeted for intervention. The intervention functions found to be most relevant included education, persuasion, modeling, incentivization, and environmental restructuring. Using the TDF, this study found that the primary factors associated with individual practice were opinion leaders, practice conformity, and reputational concerns. These findings are important because they challenge traditional dogma, which relies mainly on dissemination of published evidence, education, and technical skills acquisition to achieve evidence-based practice. Such knowledge allows for the development of sustainable, theory-based interventions for adherence to evidence-based guidelines.

Pattern of abdominal wall herniae in females: a retrospective analysis.

Gender differences are expected to influence the pattern and outcome of management of abdominal wall hernias. Some of these are left to speculations with few published articles on hernias in females. To describe the clinical pattern of abdominal wall hernias in females. A 5 year retrospective review. There were 181 female patients with 184 hernias representing 27.9% of the total number of hernia patients operated. Mean age was 41.66±24.46 years with a bimodal peak in the 1(st) and 7(th) decades. Inguinal hernia accounted for majority (50.5%) but incisional hernia predominated in the 30-49 age group, while only inguinal and umbilical hernias were seen in the first two decades (p=0.04). There was no side predilection in the cases of inguinal hernia. There were 12 (6.6%) emergency presentations, most of which occurred in the 6th decade and above and none below 30 years (p=0.02). Umbilical (4 cases) and femoral hernias (3cases) accounted for most of these cases. Incisional hernia was the commonest cause of recurrent hernias. Inguinal hernia is the commonest hernia type in females followed by incisional hernias which also accounteds for most recurrent cases. Age appears to be a risk factor for developing complications.

Design and implementation of the Americas Hernia Society Quality Collaborative (AHSQC): improving value in hernia care.

Wide variation in care and costs exists regarding the management of abdominal wall hernias, with unproven benefit for many therapies. This work establishes a specialty society-based solution to improve the quality and value of care delivered to hernia patients during routine clinical management on a national scale. The Americas Hernia Society Quality Task Force was charged by the Americas Hernia Society leadership to develop an initiative that utilizes the concepts of continuous quality improvement (CQI). A disease-based registry was created to collect information for CQI incorporating real-time outcome reporting, patient reported outcomes, stakeholder engagement, and collaborative learning methods to form a comprehensive quality improvement effort. The Americas Hernia Society Quality Collaborative (AHSQC) was formed with the mission to provide health care professionals real-time information for maximizing value in hernia care. The initial disease areas selected for CQI were incisional and parastomal hernias with ten priorities encompassing the spectrum of care. A prospective registry was created with real-time analytic feedback to surgeons. A data assurance process was implemented to ensure maximal data quality and completeness. Four collaborative meetings per year were established to meet the goals of the AHSQC. As of the fourth quarter 2014, the AHSQC includes nearly 2377 patients at 38 institutions with 82 participating surgeons. The AHSQC has been established as a quality improvement initiative utilizing concepts of CQI. This ongoing effort will continually refine its scope and goals based on stakeholder input to improve care delivered to hernia patients.

A5133 - Multi-Institutional Experience on the Surgical Management of Abdominal Wall Hernias in Patients Undergoing Bariatric Surgery

A5133 - Multi-Institutional Experience on the Surgical Management of Abdominal Wall Hernias in Patients Undergoing Bariatric Surgery

The management of abdominal wall hernias - in search of consensus.

IntroductionLaparoscopic repair is becoming an increasingly popular alternative in the treatment of abdominal wall hernias. In spite of numerous studies evaluating this technique, indications for laparoscopic surgery have not been established. Similarly, implant selection and fixation techniques have not been unified and are the subject of scientific discussion.AimTo assess whether there is a consensus on the management of the most common ventral abdominal wall hernias among recognised experts.Material and methodsFourteen specialists representing the boards of European surgical societies were surveyed to determine their choice of surgical technique for nine typical primary ventral and incisional hernias. The access method, type of operation, mesh prosthesis and fixation method were evaluated. In addition to the laparoscopic procedures, the number of tackers and their arrangement were assessed.ResultsIn none of the cases presented was a consensus of experts obtained. Laparoscopic and open techniques were used equally often. Especially in the group of large hernias, decisions on repair methods were characterised by high variability. The technique of laparoscopic mesh fixation was a subject of great variability in terms of both method selection and the numbers of tackers and sutures used.ConclusionsRecognised experts have not reached a consensus on the management of abdominal wall hernias. Our survey results indicate the need for further research and the inclusion of large cohorts of patients in the dedicated registries to evaluate the results of different surgical methods, which would help in the development of treatment algorithms for surgical education in the future.

Open extraperitoneal mesh repair for abdominal wall hernias in females.

To determine the outcome of treatment in terms of infection and recurrence using open extraperitoneal mesh repair technique. Quasi-experimental study. The department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment, from February 2006 to November 2008. Female patients with abdominal wall hernias with defect of 4 cm or more were studied. A history of previous surgery along with clinical findings on examination like size of defect and previous scar were noted. At surgery, hernial sacs were carefully opened and omental and intestinal adhesions were carefully separated. Polypropylene mesh was placed over extraperitoneal space and secured with interrupted vicryl 2/0 sutures. Redivac drains were placed over the mesh and the fascial repair. The patients were discharged on the 3rd - 4th postoperative day and were followed-up at 3 monthly intervals for postoperative sequelae like seroma, haematoma, infection and recurrence. There were 32 cases with a mean age of 41.25 + or - 10.79 years. The mean follow-up period was 15.78 + or - 9.02 months. Previous abdominal surgical intervention was found in 16 (50%) cases. Out of those, 14 (43.7%) had defects through the previous scar. A history of multiple caesarean sections alone, or in combination with either hysterectomy or laparotomy in the last 5 years was present in 7 patients. There were 12 (37.5%) cases of paraumbilical hernia, 4 (12.5%) of a recurrent paraumbilical hernia, 5 (15.6%) epigastric hernia, 2 (6.2%) mix hernia, 7 (21.8%) incisional hernia and 1 (3.1%) each of Spigelian hernia and postlaparoscopic cholecystectomy portal (paraumbilical) hernia. The mean size of the defect was 4.9 cm in primary paraumbilical hernias and 7.2 cm in recurrent paraumbilical hernias. The mean size of the defect in incisional hernias was 9.4 cm, larger than all other types. Superficial wound infection was seen in only 1 morbidly obese (BMI > 30) patient. No case of seroma, haematoma, deep seated abscess or recurrence was noted in the follow-up period. Abdominal wall hernias are common in female patients, especially those with previous surgical intervention. Open extraperitoneal mesh repair with placement of redivac drains is an effective method for the management of abdominal wall hernias with a smaller complication rate and less recurrence.

The single-staged approach to the surgical management of abdominal wall hernias in contaminated fields

The surgical treatment of large ventral hernias with accompanying contamination is challenging. We have reviewed our institution's experience with single-staged repair of complex ventral hernias in the setting of contamination. We retrospectively reviewed the medical records of all patients who underwent ventral hernia repairs in the setting of a contaminated field. Pertinent details included baseline demographics, reason for contamination, operative technique and details, postoperative morbidity, mortality and recurrence rates. Between December 1999 and January 2006, 19 patients were identified with ventral hernia repairs performed in contaminated fields. There were 6 males and 13 females with a mean age of 61 years (40-82), ASA 3.2 (2-4), and BMI of 34 kg/m(2) (20-65). Fourteen patients had prior mesh: prolene (9), composix (3), goretex (1), and alloderm (1). Reasons for contamination included: mesh infection (14), enterocutaneous fistula (7), concomitant bowel resection (8), chronic non-healing wound (2), and necrotizing fasciitis (1). Operative approaches included primary repair (3), component separation without reinforcement (2), and with prosthetic reinforcement (9). In five patients the fascia could not be reapproximated in the midline and the defect was bridged with surgisis (1), Marlex (1), lightweight polypropylene (1) placed in the retrorectus space, and alloderm (2). Mean operative time was 260 min (90-600). Twelve postoperative complications occurred in nine (47%) patients and included wound infection (6), respiratory failure (1), ileus (2), postoperative hemorrhage (1), renal failure (1), and atrial fibrillation (1). One patient died in this series. During routine follow-up two recurrences were identified by physical exam. This study shows that single-stage treatment of ventral hernias in contaminated fields can be accomplished with a low recurrence rate and acceptable morbidity in these extremely challenging patients.

Laparoscopic approach to incisional hernia.

After more than 8 years of working in the field, we thought it would be interesting to evaluate our experience in the laparoscopic repair of abdominal wall hernias, focusing attention on the lessons learned with time. From January 1994 to November of 2000, a total of 270 patients with abdominal wall hernias were treated in our center using the laparoscopic approach. The data collected and analyzed were preoperative evaluation, operative findings, early and long-term complications, and recurrences. The mean follow-up time was 44 months, mean surgical time was 85 min, and mean hospital stay was 1.5 days. The average number of abdominal wall defects was 4.8 per patient. There were 9 (3.3%) small bowel perforations. Conversion to open surgery was required in 1 case (0.3%). Minor early postoperative complications occurred in 38 patients (14.07%). Twenty patients (7.4%) developed persistent postoperative abdominal pain. There was 1 case (0.3%) of small bowel incarceration through the mesh border and another case (0.3%) of small bowel leakage due to ischemia and subsequent peritonitis. The relapse rate was 4.4% (12 cases). The laparoscopic approach is a valuable option in the management of abdominal wall hernias, but it requires experience in laparoscopic surgery and there is a specific learning curve for the technique.

Book Review: Martin Kurzer, Allan E Kark and George E Wantz (Eds.), "Surgical Management of Abdominal Wall Hernias"

Book Review: Martin Kurzer, Allan E Kark and George E Wantz (Eds.), "Surgical Management of Abdominal Wall Hernias"

Book Reviews : Surgical Management of Abdominal Wall Hernias

Book Reviews : Surgical Management of Abdominal Wall Hernias