Midline Hernias Research Articles

Endoscopic retromuscular technique (eTEP) vs conventional laparoscopic ventral or incisional hernia repair with defect closure (IPOM +) for midline hernias. A case-control study.

This study aimed at clinical results in terms of postoperative pain and functional recovery of new technique (eTEP) compared to IPOM + for ventral/incisional midline hernias. Recurrence rate, intra/postoperative complications and aesthetic results are secondary aims. Data from consecutive patients requiring minimally invasive hernia repair were collected. From January 2015 to September 2018, patients with midline ventral/incisional hernias underwent IPOM + were compared to patients underwent eTEP procedure from October 2018 to December 2019 in a case/control study. Thirty-nine patients in IPOM + group and 40 in eTEP group were included. No significant differences were identified when hernias types, mean defect area, mean mesh area and intraoperative/postoperative complications (except seroma rate in favor of eTEP group) were compared. Operative time and hospital stay were significantly higher in eTEP group and IPOM + group, respectively. eTEP group showed significantly less pain on 1st, 7th and 30th postoperative days than IPOM + group. Restriction of activities was significantly decreased in eTEP group on the 30th and 180th day after surgery. Significant differences were observed in terms of cosmetic results 30th and 180th days after surgery in favor of eTEP group. Average follow-up was 15months in eTEP group and 28months in IPOM + group. No recurrences were identified in eTEP group and one recurrence in IPOM + group with no significant differences. Endoscopic retromuscular technique shows significant lower postoperative pain, better functional recovery and cosmesis than IPOM + without differences in intra/postoperative complications (except seroma rate) or recurrences during the follow-up. eTEP requires longer operative time.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results.

Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation. To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach. A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported. 66 patients were included in the study. Median follow-up was 22months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12years, 30kg/m2, 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%). eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.

Adjuvant botulinum toxin for endoscopic management (preaponeurotic endoscopic repair) of severe diastasis recti

INTRODUCTION: Diastasis recti (DR) associated with midline hernias is common. Big size DR represents a clinical and cosmetic problem. Its repair is challenging, with intraoperative and postoperative risks. The adjuvant of botulinum toxin serotype A makes it possible to restoration of the linea alba by preaponeurotic endoscopic repair (REPA).METHODS: This was a retrospective study with prospective database. Between February 2019 and July 2020, six women were operated, with a mean age of 39 years and a diagnosis of DR >80 mm, with a body mass index of 27. All patients were infiltrated with 50 UR of botulinum toxin serotype A on each side, 30 days before the surgery.RESULTS: The intraoperative diagnosis of DR was 87.5 mm average, associated with midline hernias in 100%, with a mean transverse diameter of 24 mm (10–60 mm) Anatomical restoration of the linea alba was performed with a slow absorbable barbed suture. The wall was reinforced with 100% macroporous polypropylene mesh, with 83.3% atraumatic fixation and 16.6% absorbable traumatic fixation. The surgical time was 94 ± 15 min. Postoperative pain was 2/10 ± 1 according to the Visual Analog Scale, allowing a hospital stay of 18 ± 4 h. Return to work 18 ± 3 days. The mean follow-up was 9 (2–18) months by the clinical and ultrasound examination in 100%, without complications or recurrences.CONCLUSIONS: The application of botulinum toxin serotype A associated with endoscopic repair (REPA) allowed solving the big size DR and midline hernias with suture of the rectus sheath with less tension, associated with a reinforcement prosthesis, allowing a reduced hospitalization with a low level of postoperative pain, avoiding muscle release incisions, which are irreversible and not exempt from morbidity, added to the proven benefits of endoscopic access.

Prospective observational study of abdominal wall reconstruction with THT technique in primary midline defects with diastasis recti: clinical and functional outcomes in 110 consecutive patients.

Surgical treatment of diastasis recti is still a matter of debate. Open approaches such as abdominoplasty, which offer the possibility to combine reparation of the diastasis with abdominal cosmetic surgery, are challenged by the emerging less-invasive laparoscopic or robotic techniques that offer shorter recovery for patients. However, evidence in favour of one of the two approaches concerning both short- and long-term complications and functional results is still lacking. In this paper, we analysed clinical and functional results of a new endo-laparoscopic technique for midline reconstruction (THT technique) in patients with primary abdominal wall defects associated with diastasis recti. Prospective observational study on 110 consecutive patients was submitted to endo-laparoscopic reconstruction of the abdominal wall with linear staplers. Morbidity and relapse rates with clinical and radiological follow-up were recorded at 1, 6, 12, and 24months after the operation. Data regarding the impact of surgery on patients' quality of life (EuraHSQol) on chronic low back pain (Oswestry Disability Index, ODI) and urinary stress incontinence (Incontinence Severity Index, ISI) were gathered. After a mean follow-up of 14months, the morbidity rate was 9.1% and no recurrences were recorded. 6-month follow-up ultrasound showed a rectus muscles mean distance of 6.7mm; EuraHSQol, ODI, and ISI scores significantly improved in 93%, 77%, and 63% of the cases, respectively. The THT technique proved to be a feasible, safe, and effective alternative for corrective surgery of primary midline hernias associated with diastasis recti. Short- and mid-term results are encouraging but need to be confirmed by further studies with longer follow-up. The achieved midline reconstruction offers a significant improvement of patients' perceived quality of life through reduction of abdominal wall pain, bulging, low back pain, and urinary stress incontinence.

The darn technique for small (< 2cm diameter) midline hernias.

Primary midline hernias arising in the linea alba are common. While mesh repair has been shown to reduce recurrence rates even in small hernias, many surgeons still use a suture repair for defects of less than 2cm. The recent European and Americas Hernia Societies Guidelines recommended suture repair only for hernias smaller than 1cm. A suture repair implies edge-to-edge or overlapping fascial margins, which necessarily involves tension on the repair. A darn is a tension-free repair where, in effect, a "mesh" is hand-woven across the defect in situ. The darn repair is a modification of the darn techniques for inguinal hernia repair. Eligible patients undergoing this repair at the Royal Infirmary of Edinburgh between 1 January 2008 and 31 December 2017 were identified from a prospective computer-based medical record system and their case notes reviewed. Inclusion criteria were adult patients with a primary midline abdominal wall defect smaller than 2cm in the widest diameter of the hernia defect measured intra-operatively. Patients were followed up by telephone in 2019. Those who reported possible recurrence or other symptoms in the region of their hernia repair were reviewed in the outpatient clinic. 47 suture-darn repairs were undertaken over the 10-year period. Fifteen of the darn repair operations (32%) were performed under local anaesthesia. Forty-one patients were followed up with a mean of 80 ± 35 and median of 87months after surgery. Six patients (13%) were lost to follow-up. Recurrence was found in two cases (5%) and one patient has since been diagnosed with a new epigastric hernia some 5cm cranial to the previous repair. The darn repair for small primary midline hernias is quick and inexpensive with promising long-term results. It can be performed under local anaesthesia. It can serve as an alternative to mesh repair for defects less than 2cm in maximum dimension.

Laparoscopic diastasis recti abdominis and midline hernia repair.

Diastasis recti abdominis (DRA) is defined as an abnormally wide distance separates the two rectus muscles. Thinning and widening of the linea alba is an important risk factor for development midline hernia. In patient with DRA there is an increase rate of hernia recurrence. We perform a retrospective study to assess the outcome of laparoscopic intraperitoneal hernia repair and linea alba plication combined with mesh placement to obtain an adequate overlap of midline hernia associated to an abdominal wall support. The inclusion criteria were patients who has a clinical diagnosis of primary midline hernias of any size with associated diastasis recti. The exclusion criteria were incisional hernias, hernias outside of the midline. A total of 12 patients fulfilled the inclusion criteria. No complication was observed over the follow-up period. The rates for recurrence were 0% over the follow-up period. Despite the limited data some assumptions can be drawn from this study. The presence of DRA and coexisting hernia involves a challenging choice of the surgical treatment. Whichever approach is taken, in order to achieve an effective correction, plication of the linea alba is required. The major goal of any abdominal wall repair is not only reduction of hernia sac and prevention of further herniation but also restoration of the integrity and restitution of abdominal wall functionality. A laparoscopic approach to midline hernias associated to DRA is feasible and reproducible. It is necessary future prospective studies on larger numbers to improve knowledge on the management of DRA.

Surgical treatment of diastasis recti: the importance of an overall view of the problem.

Diastasis recti (DR) is characterized by an alteration of the linea alba with increased inter-recti distance (IRD). It is more frequent in females, and when symptomatic or associated with midline hernia it needs to be surgically repaired. This retrospective study aims to demonstrate how an overall approach to DR leads to good results in terms of functional and morphological outcomes and quality of life (QoL). From January 2018 to December 2019, 94 patients were operated for DR > 50mm, with or without midline hernias. Three different surgical approaches were used: complete laparoabdominoplasty, laparominiabdominoplasty and minimally invasive (endoscopic) technique. QoL was assessed with the EuraHS-QoL tool. All patients were female except two males. We performed 26 endoscopic treatments (27.7%), 39 laparoabdominoplasties (41.5%) and 29 laparominiabdominoplasties (umbilical float procedure) (30.9%). The total median operative time was 160min. No intraoperative complications were registered. In three (4.2%) cases, major surgical complications occurred, all after open operations. In 13 open surgery cases, vacuum-assisted closure (VAC) therapy was used to repair the cutaneous ischemic defect. No recurrence was registered to date. Minimally invasive surgery showed fewer complications and lower hospital stay than the open approach. The QoL was significantly improved. Our experience shows the importance of an overall view of the functional and cosmetic impairment created by DR. The surgeon should obtain an optimal repair of the function, by open or minimally invasive surgery, also considering the morphological aspects, which are very important for the patients in terms of QoL.

Hartmann's reversal as a safe procedure for selected patients: analysis of 199 patients at a high-volume center in Sao Paulo.

We analyzed the morbidity and mortality associated with Hartmann's reversal (HR) and the risk factors for major complications and mortality. The subjects of this retrospective study were patients who underwent HR in a high-volume center. We evaluated complications as categorical variables using univariate analyses. Between 2003 and 2018, 199 patients underwent HR at our hospital [56.5years; body mass index (BMI): 26.3kg/m2; American Society of Anesthesiology score (ASA) 3: 7.5%; 36.2% had hernias]. The mean time to HR was 20.2months and the mean operation time was 302min. The anastomosis was stapled in 71.4% and was performed in the low/medium rectum in 21.6%. Midline hernias were repaired with mesh in 80.1%. The mean hospitalization period was 10.1days. Surgical site infection (SSI) developed in 27.1% of the patients, 94.4% of whom were treated at the bedside. BMI was a risk factor for SSI (27.8 vs. 25.6; p = 0.047). Major complications (Clavien-Dindo III-V) developed in 27 patients (13.5%), including anastomosis dehiscence in 2.5%. ASA, BMI, age, hernia repair, and rectal stump size were not associated with major complications. The mortality rate was 2.5%. An ASA of 3 was associated with high mortality (p = 0.03). Hartmann's reversal remains challenging but can have low complication and mortality rates if performed on selected patients in a reference center. An ASA of 3 was the only predictor of mortality.

Minimally invasive Venetian blinds ventral hernia repair with botulinum toxin chemical component separation.

Laparoscopic ventral repair is safe, with lower wound infection rates compared with open repair. 'Venetian blinds' technique of plication in combination with mesh reinforcement, is totally intra-corporeal, with hernia defect and sac plication to reduce seroma formation. While laparoscopic suturing of the abdominal wall can represent a technical challenge, pre-operative botulinum toxin A (BTA) injections as an adjunct can assist. This study aims to demonstrate feasibility and efficacy of this technique in abdominal wall hernia repair, with BTA adjunct in midline hernias. A single-centre case series was conducted using minimally invasive 'Venetian blinds' technique for repair of complex ventral abdominal hernias. Twelve patients (seven midline, five non-midline) underwent repair (11 laparoscopic; one robotic). Midline hernias received BTA (200-300 units Botox) 4-6 weeks prior to surgery. Repairs were mesh-reinforced following fascial closure. Twelve (10 female, two male) patients, with a median age 72 years (range 31-83) and body mass index of 27.3 kg/m2 (range 22.8-61.7) were included. The median length of operation was 133 min (range 45-290) and length of hospital stay 3 days (range 1-28). To date there has been no recurrence of hernia. A single symptomatic seroma was treated with antibiotics and did not require mesh removal. One patient developed hospital-acquired pneumonia and pseudomembranous colitis. Minimally invasive 'Venetian blinds' technique has promising early results with both midline and non-midline ventral hernias. The addition of BTA is a novel and feasible combination for repair of midline ventral hernias.

Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach?

Ventral hernia repair has become a common procedure, but the way in which it is performed still depends on surgeon's skill, experience, and habit. The initial open approach is faced withextensive dissection anda high risk of infection and prolonged hospital stay. To tackle these problems, minimally invasive procedures are gaining interest. Several new techniques are emerging, but laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. We will discuss why laparoscopic IPOM is still a valuable approach in the treatment of primary non-complicated midline hernias and review the current literature. We performed a literature search across PubMed and MEDLINE using the following search terms: "Laparoscopic hernia repair", "Ventral hernia repair" and "Primary ventral hernia". Articles corresponding to these search terms were individually reviewed by the primary author and selected on relevance. Laparoscopic IPOM still is a good approach for the efficient treatment of primary non-complicated midline hernias. Several techniques are emerging, but are faced with increased costs, technical difficulties, and low study patient volume. Further research is warranted to show superiority and applicability of these new techniques over laparoscopic IPOM, but until then laparoscopic IPOM should remain the go-to technique.

Evaluation of early outcome and complications of Lap TARM

LeBlanc and Booth in 1993 first reported application of intra-peritoneal onlay mesh (IPOM) for ventral and incisional hernia. It is based on the principles of Rives-Stoppa technique of repair of ventral hernia in which a large pre-peritoneal mesh is placed and stipulated even distribution of force throughout the mesh area resulting in stronger repair than onlay mesh technique. Laparoscopic technique was adopted in an effort to reduce wound complications, post-operative pain and early return to work. Since then various methods of laparoscopic repair have been performed and studied in an effort to find out the most suitable, least expensive way to deal with ventral hernias. LVHR is a safe alternative to the open method, with the main advantages being minimal postoperative pain, shorter recovery, and decreased wound and mesh infections. This is a retrospective study in which we evaluated the performance of 10 cases of Laparoscopic TARM (Trans Abdominal Retro rectus Mesh repair) from Oct 2018 to Jul 2019. This study is being conducted to evaluate early outcome and complications of this procedure amongst the initial cases at our institute. We chose midline hernias only, both Primary and Incisional, for feasibility to do TARM procedure in retrorectus space. Patients were evaluated for post-operative outcome in terms of pain, local collection and intestinal obstruction. Pain was experienced in mild-moderate degree in four patients, collection in three and small bowel obstruction in two patients. Early results indicate that TARM can be performed as a cheaper alternative to IPOM mesh repair. Further studies are needed to establish this procedure as the preferred method for treatment of midline hernias.

Peritoneal Flap Hernioplasty for Reconstruction of Large Ventral Hernias: Long-Term Outcome in 251 Patients

BackgroundRepair of large ventral hernias is challenging when primary fascial closure cannot be achieved. The peritoneal flap hernioplasty, a modification of the Rives-Stoppa retromuscular mesh repair, addresses this problem by using the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space. It is applicable to both midline and transverse hernias. We report the results from our institution using this repair based on a retrospective review of 251 cases.MethodsPatients undergoing peritoneal flap hernioplasty repair from January 1, 2010–December 31, 2014 were identified from the Lothian Surgical Audit system, a prospectively maintained computer database of all surgical procedures in the Edinburgh region of southeast Scotland. Patient demographics, clinical presentation, location of the hernia and surgical treatment were obtained from the hospital case-notes. Follow-up consisted of a clinical consultation 3 months postoperatively and a retrospective review of patient files completed December 2018. Patients presenting signs of complications were assessed during a clinical review.ResultsTwo hundred and fifty-one patients underwent incisional hernia repair, 68.1% in the midline and 31.9% arising through transverse incisions. Forty-three of these (17%) were recurrences referred from other centers. Mean BMI was 32.1 kg/m2 (range 20–59.4 kg/m2). Mean defect width was 9.2 ± 4.2 cm (range 2.5–24.2 cm). Mean mesh size was 752 cm2 (range 150–1760 cm2). Some form of abdominoplasty was performed in 59% of cases. Mean postoperative stay was 6.3 days (range 1–33 days). Mean follow-up time was 75 months (range 44–104 months). Fifty-three patients (21.1%) developed postoperative complications. Three (1.2%) developed superficial skin necrosis and 27 (10.8%) a superficial wound infection, but none developed deep mesh infection. Twelve (4.8%) developed symptomatic seroma and 11 (4.4%) a hematoma requiring surgical intervention. Seven (2.8%) patients developed recurrence within the follow-up period.ConclusionPeritoneal flap hernioplasty is an excellent and versatile method for reconstruction of large ventral hernias arising in both midline and transverse incisions. The technique is safe and associated with few complications and a very low recurrence rate.

Totally Endoscopic Sublay Anterior Repair for Ventral and Incisional Hernias.

Endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. To combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose Totally Endoscopic Sublay Anterior Repair (TESAR) a safe and feasible approach for the treatment of ventral and incisional midline hernias. From May to November 2018, 12 patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for TESAR. Exclusion criteria were: complicated ventral or incisional hernia (i.e., incarcerated hernia), maximum defect width >7 cm, and contraindications to general anesthesia. All procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. No intraoperative complications were registered. Total mean operative time was 148 ± 18.5 minutes. No postoperative major complications were registered. Only one subcutaneous seroma was registered (8.3%) and treated conservatively. The mean postoperative stay was 2.6 ± 0.6 days. TESAR is a safe and feasible technique for the extraperitoneal sublay repair of ventral hernias with a totally endoscopic approach. It provides accurate hernia repair with good outcomes in terms of resolution of symptoms and postoperative complications.

Subcutaneous Videosurgery for Abdominal Wall Defects: A Prospective Observational Study.

Abdominal wall defects (AWDs) include recti diastasis and midline hernias (umbilical, epigastric, and incisional). In the coexistence of such fascia defects, simultaneous repair is recommended. Conventional and hybrid techniques have been reported as an option of approach. This study aims to present the results of a total minimal invasive access to treat AWD with mesh reinforcement (subcutaneous videosurgery for abdominal wall defects [SVAWD] technique). The prospective observational study included patients with small/medium midline incisional hernia and/or multiple AWDs (symptomatic umbilicus and/or an epigastric hernia and/or abdominal rectus diastasis >2 cm) operated between August 2016 and February 2018. The exclusion criteria were, namely, fascia defects >10 cm, complex hernias, excess of skin and/or subcutaneous abdominal fatty tissue, and body mass index >35 kg/m2. Twenty-one patients were treated by SVAWD technique, with a median follow-up of 14 (range 6-22) months. The mean size of all fascia defects was 7.46 cm (range 4.5-10.5). Surgical site occurrence was identified in three (14.3%) patients and surgical site occurrence requiring procedural intervention in two (9.5%). Diabetes mellitus was the only predictor factor for higher intraoperative bleeding (R2 = 0.63, P = .025). Fibrin sealant (used for mesh fixation) and transverse abdominis plane (TAP) block with ropivacaine 0.2% were associated with less oral analgesics intake (P < .001 and P < .001, respectively) and fewer complications (P = .005 and P = .034, respectively). Despite the low number of patients operated, the subcutaneous approach presented has proven to be safe, feasible, and effective, as no major complications and relapse occurred. Still, fibrin sealant and TAP block were associated with fewer complications and less oral analgesics intake.

Preaponeurotic endoscopic repair (REPA) of diastasis recti associated or not to midline hernias

Diastasis recti is a common pathology during pregnancy and puerperium, usually associated with midline hernias, with aesthetic and symptomatic problems. This approach allows us to restore the alba line, without entering the abdominal cavity. Between April 2014 and July 2017, 50 patients underwent surgery, 94% female (mean age 38). Ultrasonography confirmed diagnosis. Recti diastasis was associated with midline defects in 100%. The preaponeurotic endoscopic repair is done with suprapubic approach and in both iliac fossae. A preaponeurotic new cavity was created with dissection of the subcutaneous cellular tissue and then recti plication with barbed suture was performed. The wall is reinforced with polypropylene mesh. Drainage is left systematically. Diastasis recti < 50mm (55.5%) was diagnosed, from 51 to 80mm (29.6%), and > 81mm (14.9%). Recti plication with bearded suture was performed. It was associated with external oblique release in 32% of patients, being unilateral (87.5%). Light/intermediate (90%) and heavy (10%) polypropylene meshes were placed, being fixed with absorbable (62%) and non-absorbable material (38%). Navel was reinserted using internal or external sutures. The average surgical time is 83min. There are no intraoperative complications, but PO seroma finding 12%. The average hospital stay was 1.3days, with pain level 3/10 according to AVS. The patients returned to their usual activities after 16.5 days. No complications or recurrences were observed by clinical and sonographic control at 18months in 74% of patients. The patients were followed up at 39 months. Patient satisfaction was reported as 96%. Diastasis recti is a common pathology with aesthetic and symptomatic problems. Endoscopic surgery allowed us to resolve the parietal defect with plication of recti and placement of preaponeurotic reinforcement prosthesis, increasing the safety of the repair, without entering the abdominal cavity, with a short hospitalization and no complications or recurrence in 3years.

A Current Review of Synthetic Meshes in Abdominal Wall Reconstruction.

The use of mesh materials for reinforcement of the abdominal wall has revolutionized the approaches to hernia repair. Whether it's a permanent, synthetic mesh, a biologically derived collagen graft, or a synthetic, bioresorbable construct, data demonstrate improved outcomes with respect to recurrence with their use. Numerous advances and development of component separation techniques of the abdominal wall musculature have provided surgeons the ability to close large fascial defects and reestablish the linea alba for midline hernias. Augmentation of the these repairs with a mesh helps to offset the tension on the fascial closure and provide biomechanical strength to the native tissue. However, the use of mesh materials as either permanent or temporary scaffolds is not without potential complications. Abdominal wall surgeons must have knowledge of the mesh composition and structure in an effort to mitigate these concerns. This chapter will review the polymers and characteristics of the currently available synthetic meshes for abdominal wall reconstruction in an effort to provide guidance to surgeons.

Laparoscopic intracorporeal rectus aponeuroplasty (LIRA technique): a step forward in minimally invasive abdominal wall reconstruction for ventral hernia repair (LVHR).

Closing the defect (CD) during laparoscopic ventral hernia repair began to be performed in order to decrease seroma, to improve the functionality of the abdominal wall, and to decrease the bulging effect. However, tension at the incision after CD in large defects is related to an increased rate of pain and recurrence. We present the preliminary results of a new technique for medium midline hernias as an alternative to conventional CD. A prospective controlled study was conducted from January 2015 to January 2017 to evaluate an elective new procedure (LIRA) performed on patients with midline ventral hernias (4-10cm width). The posterior rectus aponeurosis was opened lengthwise around the hernia defect using a laparoscopic approach to create two flaps and was then sutured. The size of the flaps was estimated using a mathematical formula. An on-lay mesh was placed intraperitoneal overlapping the fascia defect. The data analyzed included patient demographics, operative parameters, and complications. A computerized tomography was performed preoperatively and postoperatively (1month and 1year) to evaluate recurrence, distance between rectus and seroma. Twelve patients were included. Mean width of the defect was 5.5cm. Average VAS (24h) was 3.9, 1.1 (1month), and 0 (1year). Mean preoperative distance between rectus was 5.5cm; postoperative was 2.2cm (1year). Radiological seroma at first month was detected in 50%. Mean follow-up was 15months. The LIRA technique could be considered as an alternative to conventional CD or endoscopic component separation for medium defects under 10cm in width. This technique obtained a "no tension" effect that could be related to a lower rate of postoperative pain with no recurrence or bulging, being a safe, feasible, and reproducible technique.

Mesh sutured repairs of contaminated incisional hernias

BackgroundWe sought to evaluate the results of a new mesh sutured repair technique for closure of contaminated incisional hernias. Methods48 patients with contaminated hernias 5 cm wide or greater by CT scan were closed with mesh sutures. Surgical site occurrence, infections, and hernia recurrence were compared to similar patient series reported in the literature. ResultsOf the 48 patients, 20 had clean-contaminated wounds, 16 had contaminated wounds, and 12 were infected. 69% of the patients underwent an anterior perforator sparing components release for hernias that averaged 10.5 cm transversely (range 5 cm–25 cm). SSO occurred in 27% of patients while SSI was 19%. There were no fistulas or delayed suture sinuses. With a mean follow-up of almost 12 months, 3 midline hernias recurred (6%). In these same patients, three parastomal hernias repaired with mesh sutures failed out of 4 attempted for a total failure rate of 13%. ConclusionMesh sutured closure represents a simplified and effective surgical strategy for contaminated midline incisional hernia repair.

How to perform the endoscopically assisted components separation technique (ECST) for large ventral hernia repair.

The components separation technique (CST) is frequently used for reconstructing large ventral hernias. Unfortunately, it is associated with a high wound complication rate up to 50%, caused by large wound surface and inherent trauma to abdominal skin vascularization. An endoscopically assisted modification of the original technique (ECST) spares skin vascularization and reduces wound surface, supposedly reducing wound complications. This study accurately describes ECST step by step with detailed illustrations and report the results of a 27 patient cohort. Since September 2012 patients with midline hernias without previous subcutaneous dissection and a maximum diameter of approximately 10-15cm underwent ECST in an expert centre for abdominal wall reconstructions. Prospective data was gathered during inpatient care and 3-6 monthly follow-up. Twenty-seven patients (17 male/10 female) with median age of 60years (range 35-77), average BMI 27 (SD ±2)kg/m(2) and median ASA classification 2 (range 1-3) underwent ECST. Two patients were excluded due to bilateral conversion to conventional CST and finding of peritoneal metastases. Median defect size was 116±48cm(2). Median length of stay was 5days (range 3-15). Wound complication rate was 11%. Recurrence rate was 29% after a median follow-up of 13months. Endoscopically assisted modification of the original technique can be used for reconstructing large and complex ventral hernias up to 15cm in diameter. The results of this small sized cohort study showed that ECST is feasible in patients with a uro-, or enterostomy and suggest that ECST reduces wound complication rate when compared to CST.

Proposed technique for open repair of a small umbilical hernia and rectus divarication with self-gripping mesh.

There are a group of patients in which umbilical or epigastric hernias co-exist with rectus divarication. These patients have weak abdominal musculature and are likely to pose a higher risk of recurrence following umbilical hernia repair. We would like to describe a technique for open repair of small (<4cm) midline hernias in patients with co-existing rectus divarication using self-adhesive synthetic mesh. The use of a self-adhesive mesh avoids the need for suture fixation of the mesh in the superior portion of the abdomen, allowing for a smaller skin incision. In 173 patients, preperitoneal self-fixating mesh has been used for the repair of midline hernias <4cm in diameter. In 58 of these patients, the mesh was extended superiorly to reinforce a concurrent divarication. The described technique offers a simple option for open repair of small midline hernias in patients with co-existing rectus divarication, to decrease the risk of upper midline recurrence in an at-risk patient group.This initial case series is able to demonstrate a suitably low rate of recurrence and complications.