Primary Hernia Repair Research Articles

Long-term incidence of contralateral primary hernia repair following unilateral inguinal hernia repair in a cohort of 32,834 patients.

Asymptomatic contralateral inguinal hernias are often present during initial inguinal hernia repair. Data on long-term results and progression to symptomaticity are sparse. The purpose of this study was to assess long-term rates and risk factors for contralateral inguinal hernia repair following unilateral inguinal hernia repair. Using New York Statewide Planning and Research Collaborative administrative data, 32,384 adults who underwent initial inguinal hernia repair during 2002-2003 in New York State and achieved 10-year follow-up were identified. ICD-9 and CPT codes were used to identify patients. Patients were followed for 10years subsequent to their operation to assess for contralateral repair. Those who did not achieve 10-year follow-up were excluded. Risk factors were compared using descriptive univariate statistics. Significant variables were then analyzed via multivariate regression models. For adult patients having primary unilateral hernia repair, 3364 patients (6.73%) had contralateral repair during the follow-up period. After excluding "loss of follow-up" patients, the contralateral repair rate was 10.8%. Contralateral hernia repairs first occurred at a mean of 3.9±3.5years and a median of 2.5years after the initial surgery. Risk factors included age >45years (OR 1.7 [1.4-2.0], p<0.001), male gender (OR 2.2 [1.9-2.6], p<0.0001), and white race (OR 1.6 [1.1-2.4], p<0.001). Factors associated with decreased likelihood for repair included: congestive heart failure (OR 0.6 [0.4-0.9], p=0.01), diabetes (OR 0.7 [0.5-0.8], p=0.02), neurological disorders (OR 0.6 [0.4-0.9], p=0.02), obesity (OR 0.3 [0.1-0.8], p=0.01), and alcohol abuse (OR 0.2 [0.03-0.8], p=0.03). The 10-year probability of necessitating a contralateral inguinal hernia repair is significant. Elderly white males were more likely to undergo repair. Those less likely to undergo repair had significant comorbid conditions, possibly due to their poor suitability for intervention. These data highlight a key benefit of the laparoscopic approach over open repairs. Based on these data, an argument for laparoscopy with routine contralateral inspection in higher-risk patients can be made.

Does pregnancy increase the risk of abdominal hernia recurrence after prepregnancy surgical repair?

By increasing intraabdominal pressure, pregnancy may increase the risk of abdominal hernia recurrence. Current data are limited to studies with small sample size and thus the impact of pregnancy on recurrence is unclear. The objective of this analysis was to evaluate the impact of pregnancy on clinically significant abdominal hernia recurrence in a large multicenter cohort. A multiinstitution deidentified electronic health record database, EPM: Explore (Explorys Inc, Cleveland, OH) was utilized to perform a retrospective cohort study of women aged 18-45 years with a history of an abdominal hernia repair from 1999 through 2013. Abdominal hernia was defined to include ventral and incisional hernias, and other types were excluded. The presence or absence of a pregnancy following primary hernia repair was elucidated from the database. Subjects were excluded if a hernia repair occurred during pregnancy. The rate of hernia recurrence, defined as reoperation, was calculated. The association between pregnancy andhernia recurrence was evaluated with logistic regression, both unadjusted and adjusted for diabetes, obesity (body mass index >30 kg/m(2)), tobacco abuse, and wound complication at the time of initial hernia repair. A total of 11,020 women with a history of hernia repair were identified, of whom 840 had a subsequent pregnancy. Overall, 915 women in the cohort had a hernia recurrence (8.3%). Women with a history of pregnancy following primary hernia repair were more likely to have a body mass index >30 kg/m(2), a history of tobacco abuse, and awound complication at the time of primary repair. In an unadjusted analysis, pregnancy was associated with an increase in the risk of hernia recurrence (13.1% vs 7.1%, odds ratio, 1.96, 95% confidence interval, 1.60-2.42). The association between pregnancy and hernia recurrence was attenuated but persisted after adjusting for confounding factors (adjusted odds ratio, 1.73, 95% confidence interval, 1.40-2.14). Pregnancy is associated with an increased risk of abdominal hernia recurrence after adjusting for confounding factors. The magnitude of this association is likely underestimated, given that the risk of recurrence was defined as reoperation, which captures onlythe most clinically significant group of recurrences. This information will facilitate counseling for reproductive-aged women planning elective ventral or incisional hernia repair. The risk of recurrence andsubsequent reoperation should be balanced against the risk ofincarceration and emergent surgery during pregnancy. As such, thedesire for future pregnancy and/or contraception should be considered when planning asymptomatic hernia repair for women of reproductive age.

Urinary bladder matrix scaffolds strengthen esophageal hiatus repair

BackgroundLaparoscopic repair of the hiatal hernia is associated with a recurrence rate between 12% and 42% depending on the defect size. Although the impact of hiatal reinforcement on long-term recurrence remains controversial, the main limitation of this approach has been the risk of adverse events related with the use of synthetic materials in the vicinity of the esophagus. MethodsA total of 14 female domestic pigs underwent laparoscopic primary hiatal hernia repair of a simulated defect in the esophageal hiatus. Seven of the hiatal repairs were reinforced with an extracellular matrix (ECM) scaffold, whereas the remaining seven served as primary repair controls. Animals were survived for 8 wk. At necropsy, after gross morphologic evaluation, samples were sent for mechanical testing and histology. ResultsThe repaired defect site reinforced with ECM scaffolds showed a robust closure of the crura in all cases with a smooth peritoneal-like structure covering the entire repair. Average load at failure of the treated group was found to be significantly stronger than that of the controls (185.8 ± 149.7 g versus 57.5 ± 57.5 g, P < 0.05). Similarly, the stiffness was significantly higher in the treated animals (57.5 ± 26.9 g/mm versus 19.1 ± 17.5 g/mm; P < 0.01). Interestingly, there was no difference in elongation at failure (7.62 ± 2.02 mm versus 7.87 ± 3.28 mm; P = 0.44). ConclusionsIn our animal survival model, we have provided evidence that the addition of an ECM to augment a primary hiatal repair leads to tissue characteristics that may decrease the possibility of early failure of the repair. This may translate to decreased recurrence rates. Further study is necessary.

Randomized clinical trial comparing self-gripping mesh with a standard polypropylene mesh for open inguinal hernia repair.

The introduction of mesh for open inguinal hernia repair has reduced the rate of recurrence, allowing research to focus on prevention of postoperative pain. In an effort to reduce chronic pain, a semiresorbable, lighter and self-gripping mesh was developed. A double-blind randomized clinical trial was conducted comparing the self-gripping mesh with a standard polypropylene mesh repair. Patients over 18 years of age undergoing open primary hernia repair were included. Pain was measured on a six-point verbal rating scale (VRS) and a 150-mm visual analogue scale (VAS). Postoperative pain reduction from baseline pain (ΔVAS), complications and return to work/hobbies were studied. Data were collected at baseline, 3 weeks, 3 months and 1 year after surgery (primary outcome). A total of 363 patients were analysed. Median age was 59 (range 19-88) years. Baseline VRS and VAS scores were similar for the two groups. There was no difference in VRS scores at 1-year follow-up. Duration of surgery was significantly shorter with the self-gripping mesh (mean 40 min versus 49 min for standard mesh repair; P < 0·001). At 3 weeks, ΔVAS in patients receiving the self-gripping mesh was significantly larger (-10·6 versus -5·0 respectively; P = 0·049) and less subjective discomfort was reported (P = 0·016). Complication rates, return to work and recurrence rates were similar, although there were more recurrences in the self-gripping mesh group (5·5 versus 2·2 per cent; P = 0·103). A self-gripping mesh for hernia repair may result in less pain in the early postoperative phase but chronic postherniorraphy pain is not affected. Recurrence rates may be a potential disadvantage. NTR1212 (http://www.trialregister.nl).

Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register.

To investigate which type of hernia that has the highest risk of a recurrence after a primary Lichtenstein repair. Male patients operated on with a Lichtenstein repair for a primary direct or indirect inguinal hernia and with a TEP for a later recurrence, with both operations recorded in the Swedish Hernia Register (SHR), were included in the study. The study period was 1994-2014. Under the study period, 130,037 male patients with a primary indirect or direct inguinal hernia were operated on with a Lichtenstein repair. A second operation in the SHR was registered in 2236 of these patients (reoperation rate 1.7%). TEP was the chosen operation in 737 in this latter cohort. The most likely location for a recurrence was the same as the primary location. If the recurrences change location from the primary place, we recognized that direct hernias had a RR of 1.51 to having a recurrent indirect hernia compared to having a direct recurrence after an indirect primary hernia repair. Recurrent hernias after Lichtenstein are more common on the same location as the primary one, compared to changing the location.

480 Primary vs. Redo Paraesophageal Hiatal Hernia Repair: A Comparative Analysis of Operative and Quality of Life Outcomes

480 Primary vs. Redo Paraesophageal Hiatal Hernia Repair: A Comparative Analysis of Operative and Quality of Life Outcomes

Nonprosthetic Direct Inguinal Hernia Repair During Robotic Radical Prostatectomy

To report our experience with concomitant hernia repair during robot-assisted radical prostatectomy (RARP) with a nonprosthetic and tissue-based technique. We conducted a retrospective review on 1005 consecutive patients who underwent RARP between the years 2005 and 2015. Twenty-nine patients, who underwent 37, concurrent, direct, inguinal hernia repairs, were identified (group 1) and compared to a match control group of 29 patients who underwent RARP without hernia repair (group 2). Cases were matched 1:1 for age, body-mass index, and pathologic stage. The reinforcement of the floor was achieved with a modified posterior wall darn repair. The repair consisted of suturing the lateral edge of the rectus abdominis muscle sheath to the ileopectineal ligament (Cooper's ligament) with continuous prolene loose suture. This technique provided a tissue-based repair and the final reinforcement of the floor was expected to ensue by the secondary fibrotic tissue development and maturing between the sutures. From a total of 1005 patients who underwent RARP, 29 (2.8%) were preoperatively identified with a primary, direct inguinal hernia and underwent concomitant inguinal herniorrhaphy. The operative time was 147 minutes for group 1 vs 143 minutes for group 2 (p = 0.8). Estimated blood loss was 175 mL for the group with the hernia repair vs 200 mL for the group without repair (p = 0.3). There were no Clavien-Dindo grade >1 complications observed in either of the groups. Mean follow-up period was 32.1 months for group 1 vs 33.3 for group 2 (p = 0.8). Importantly, no hernia recurrences were observed. Inguinal hernias represent an important surgical issue and may be repaired concurrently during radical prostatectomy to minimize the risks of postoperative complications. The concomitant repair of inguinal hernias during robotic radical prostatectomy utilizing a nonprosthetic is a safe and feasible alternative for primary direct hernia repair during prostatectomy.

Abstract 18266: Overactive Tgfβ Signaling in Smooth Muscle Cells Induces Hypertension in Mice Through Increased Myogenic Tone and is Responsible for Increased Myogenic Tone in Resistance Vessels of Hypertensive Patients

Emilin1 (E1) is a protein of the extracellular matrix that regulates TGFβ activity through proteolysis of the proTGFβ. E1 KO mice are hypertensive, with increased TGFβ activation. As E1 is expressed in blood vessels starting from embryonic life to adulthood, is still unknown whether the E1 KO phenotype results from a developmental defect or lack of a homeostatic role exerted in the adult. To dissect this issue, we inactivated E1 in smooth muscle cells (VSMCs) of adult mice, by the use of floxed E1 and CreERT2 [a tamoxifen (TAM) inducible Cre recombinase] under the control of the smooth muscle myosin heavy chain (Smmhc) promoter. When Smmhc-CreERT2 E1fl/fl mice were given TAM, blood pressure significantly increased (124±1 vs basal condition 106±1 mmHg) as well as myogenic response in resistance arteries (16.3±0.7 vs basal condition 11.4±0.1 % at 125 mmHg). In order to evaluate the relevance of our findings in the human pathology, we enrolled 20 hypertensive and 20 normotensive patients that underwent neurosurgical intervention for primary lumbar hernia repair and dissected out resistance vessels from skeletal muscle biopsies. We analyzed the myogenic tone of human peripheral resistance vessels in a pressure myograph and randomized vessels to receive vehicle, a neutralizing antibody anti-TGFβ or a preimmune non relevant IgG. As first, we found that hypertensive patients had significantly increased myogenic tone as compared to normotensive (16.6±2.1% vs 10.5±0.4% at 125 mmHg). Moreover, the pretreatment of vessels with anti-TGFβ antibody normalized the myogenic tone of hypertensive patients (10.8±0.6%) to the levels of normotensives (11.8±1.3%). A pretreatment with the non relevant IgG did not modify the myogenic tone of hypertensives (17±0.6%), thus demonstrating that the effect was dependent of an increased TGFβ signaling in vessels of hypertensive patients. Overall, our results suggest that the TGFβ pathway in VSMC, is crucial for the myogenic tone of resistance arteries and is linked to the regulation of blood pressure. The data obtained in peripheral resistance vessels from hypertensive patients, that display an increased myogenic tone dependent on overactive TGFβ signaling, highlight the translational potential of our findings to the human pathology.

A single-centre experience of relaparoscopy in complications of laparoscopic inguinal hernia repair-feasibility and outcomes

Management of complications of laparoscopic inguinal hernia repair remains challenging as well as debatable. Relaparoscopy in management of these complications is relatively newer concept. We tried to analyse the feasibility of relaparoscopy (transabdominal preperitoneal approach) in management of complications of laparoscopic inguinal hernia repair. The study group included 61 patients (referral cases) from a prospectively maintained database of previous laparoscopic inguinal hernia surgery with majority of the patients of recurrence (n=39). Other complications were mesh infections (n=15), pubic osteitis (n=3), migration of mesh into adjacent viscera (n=3) and meralgia paresthetica (n=1). All patients underwent transabdominal preperitoneal approach (TAPP) between January 2007 and December 2013. Most of the patients had previous TEP repair (n=49) with variable complications detected in the range of 9days to 38months. Small-sized mesh (n=12) and rolled up mesh (n=10) were the causes of recurrence in 57% cases. Mycobacterium tuberculosis (40%) and mixed bacterial infections (33%) strains were detected in the infected mesh. Pubic osteitis and meralgia paresthetica were tackers induced. All patients dealt with TAPP approach. Recurrent hernia cases underwent mesh placement and infected mesh was removed in mesh infection. Tackers were removed in cases of osteitis pubis and meralgia paraesthesia. Median operative time was 62min (42-126min) and hospital stay 3days (2-13days). The relaparoscopy was accomplished in 95.1% of cases with no major intraoperative complications and minimal postoperative morbidity. Relaparoscopy through TAPP approach remains safe and feasible option to deal with primary laparoscopic hernia repair complications. Surgical techniques during primary laparoscopic repair are important cause for aforementioned complications. Though, surgical expertize remains warranted for relaparoscopy.

The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery

To evaluate the incidence and outcomes of hiatal hernias (HH) that are repaired concomitantly during bariatric surgery. We identified patients who had concomitant HH repair during bariatric surgery from 2010 to 2014. Data collected included baseline demographics, perioperative parameters, type of HH repair, and postoperative outcomes. A total of 83 underwent concomitant HH during study period. The male-to-female ratio was 1:8, mean age was 57.2 ± 10.0 years, and mean body mass index was 44.5 ± 7.9 kg/m(2). A total of 61 patients had laparoscopic Roux-en-Y gastric bypass, and 22 had laparoscopic sleeve gastrectomy. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) were diagnosed intraoperatively. Primary hernia repair was performed with anterior reconstruction in 45 (54%) patients, posterior in 21 (25%), and additional mesh placement in 7 (8%). A total of 24 early minor postoperative symptoms were reported. At 12 month follow-up, mean body mass index improved to 30.0 ± 6.2 kg/m(2), and anti-reflux medication was decreased from 84% preoperatively to 52%. Late postoperative complications were observed in 3 patients. A comparative analysis with a matched 1:1 control group displayed no significant differences in operative time (P = .07), duration of stay (P = .9), intraoperative complications, or early (P = .09) and late post-operative symptoms (P = .3). In addition, no differences were noted in terms of weight-loss outcomes. The true incidence of HH may be underestimated before bariatric surgery. Combined repair of HH during bariatric surgery appears safe and feasible.

Laparoscopic versus open ventral hernia repair in obese patients: a long-term follow-up

Ventral hernia repair in obese patients has a high perioperative morbidity and recurrence. The laparoscopic approach may reduce those rates. This study compares those outcomes following laparoscopic ventral hernia repair (LVHR) with the standard open approach (OVHR) in obese patients. A retrospective review of patients with a BMI > 30 kg/m(2) that had undergone ventral hernia repair (VHR) between 2004 and 2012 was included. Demographics, perioperative complications and recurrence rates were compared between the two approaches. Hernia size was divided into three categories (small, medium and large). Physical examination and CT imaging mainly evaluated recurrences. A total of 186 patients that underwent VHR were included, 35 patients had LVHR. Groups did not differ in terms of age, gender, ASA score, BMI and in rates of primary or incisional ventral hernia repair. The laparoscopic repairs were performed on significantly larger hernias (48.6 vs. 28.9% categorized as large, p = 0.02). The operative time was significantly longer in the laparoscopic repair (102 vs. 67 min, p < 0.01). Overall, perioperative complications following LVHR and OVHR were 17.1 versus 20.5% (p = 0.53). Wound-related complications were lower in the LVHR group (5.7 vs. 15.8%, p = 0.09). After a mean follow-up of 58 months, recurrence rates in the laparoscopic and open approaches were 20.0 versus 27.1% (p = 0.28), respectively. Advanced age was found to be a significantly protector from recurrence (OR -0.03; 95% CI 0.96-0.01, p = 0.01). OVHR carries an odds ratio of 2.7 (95% CI 0.88-8.2, p = 0.07) for recurrence compared with OVHR. The risk of recurrence after VHR in obese patients is high. Laparoscopic approach offers a better perioperative and recurrence outcome. We believe that change in those outcomes is possible through weight loss procedures, but may need further studies to be conducted in the form of prospective randomized trials.

PTU-284 Linked primary care and hospital database analysis of trends in laparoscopy, short-term complications and recurrence following inguinal hernia repair in england

<h3>Introduction</h3> In September 2004, the National Institute for Health and Care Excellence (NICE) extended their recommendations for laparoscopic inguinal hernia repair to all patients from previous guidelines pertaining to bilateral and recurrent hernias. Despite these changes in policy little is known about short-term complications that are encountered in the primary care setting. <h3>Method</h3> Linked primary (Clinical Practice Research Datalink – CPRD) and secondary (Hospital Episode Statistics – HES) care records were used to evaluate outcomes from inguinal hernia repair in England. Patients undergoing primary inguinal hernia repair between 1997 and 2012 were evaluated. In-hospital complicaitons were measured in HES, out-of-hospital complications were measured in CPRD and reoperation for recurrence was measured in HES. <h3>Results</h3> From these datasets, 34400 primary hernia repairs performed in 32410 patients were evaluated. Of these repairs, 7.4% (2541/34400) were performed laparoscopically. The proportion of laparoscopic inguinal hernia repair increased after the introduction of guidelines in September 2004. Short-term complications were lower for laparoscopic (1.85% – 47/2541) compared with open (3.57% – 1138/31859) repair, but surgery for recurrence was more frequent following laparoscopic repair (laparoscopic 3.31% 84/2541, open 1.15% 366/31859) (p &lt; 0.001). There were no differences in the rate of short-term complications before (3.53% – 18405) and after (3.35% – 536/15995) the introduction of guidelines, while surgery for recurrence was more frequent after the introduction of guidelines (pre-guidelines 1.50% 240/15755, post-guidelines 1.14% 210/18405, p = 0.004). Independent predictors of short-term complications were age (OR = 1.01), body mass index (OR = 1.03), peptic ulcer disease (0.002), respiratory disease (OR = 1.26), bilateral repair (OR = 1.50), open surgery (OR = 1.38) and emergency surgery (OR = 2.13) (p &lt; 0.05). Independent predictors of surgery for recurrence included bilateral repair (OR = 3.67), laparoscopic repair (OR = 1.49), surgery after the introduction of guidelines (OR = 1.24) and wound infection (OR = 1.79) (p &lt; 0.05). <h3>Conclusion</h3> Laparoscopic inguinal hernia repair was associated with significantly lower short-term complication rates compared with open surgery, but significantly increasaed rates of surgery for recurrence. It is important that further dissemination of the technique is accompanied by adequate training to ensure longer term durability. <h3>Disclosure of interest</h3> None Declared.

Adverse Events after Ventral Hernia Repair: The Vicious Cycle of Complications

Ventral hernia repairs are one of the most common procedures performed by the general surgeon. They are also among the most complex procedures performed. We hypothesized that with each surgical failure, subsequent ventral hernia repair becomes more complicated and morbid. We assessed a multicenter database of patients who underwent an elective ventral hernia repair from 2000 to 2012 with at least 6 months of follow-up and elective repairs. Patients were evaluated by the number of previous ventral hernia repairs they had: primary ventral hernia repair (PVHR), first time incisional hernia repair (IHR1), second time incisional hernia repair (IHR2), or third time or greater incisional hernia repair (IHR3). The main outcomes measured were abdominal reoperation, operative duration, surgical site infection (SSI), and hernia recurrence. Complications were assessed and compared between the 4 groups. Time to recurrence was estimated using the Kaplan-Meier curve method by study cohort (PVHR, IHR1, IHR2, IHR3). A total of 794 patients were assessed; of these, 481 (60.6%) had PVHR, 207 (26.1%) had IHR1, 78 (9.8%) had IHR2, and 28 (3.5%) had IHR3. Patients with multiple repairs were more likely to undergo subsequent reoperation, have a longer operative duration, develop SSI, and have a recurrence. At 140 months of follow-up, 37% of primary ventral hernias and 64% of incisional hernias have recurred. The highest recurrence rates are seen in IHR3, with 73% recurring. Previous ventral hernia repair increases the complication profile of repair, creating a vicious cycle of repair, complications, reoperation, and re-repair. Furthermore, long-term outcomes for ventral hernia repair are poor. Future studies should focus on hernia prevention and improving long-term outcomes after hernia repair.

Mesh fixation techniques in primary ventral or incisional hernia repair

Mesh fixation techniques in primary ventral or incisional hernia repair

A case of traumatic abdominal wall hernia with delayed bowel obstruction.

BackgroundTraumatic abdominal hernia is rare and difficult to diagnose from physical symptoms.PatientA 60-year-old woman was admitted to the emergency department with complaints of vomiting after falling off a bicycle and hitting her abdomen against one of the handlebars 2 days earlier. Computed tomography (CT) demonstrated abdominal wall hernia from blunt trauma to the left upper abdomen. The patient underwent exploratory laparotomy, and the herniated bowel loop was not found to be perforated or gangrenous. Primary hernia repair without resection of the bowel loop was performed.ResultsPostoperative course was uneventful.ConclusionSurgical exploration with primary repair of the defect is the definitive treatment in the present case, as the hernia contained an incarcerated loop of small bowel. The use of abdominal CT to confirm the diagnosis before operative repair of the hernia appears to be a safe and efficacious adjunct to physical examination.

Groin hernia subtypes are associated in patients with bilateral hernias: a 14-year nationwide epidemiologic study.

To investigate the relation between groin hernia subtypes in patients operated for bilateral hernias. With data from the Danish Hernia Database, we identified all patients operated for primary groin hernias from 1998 to 2012. Within this cohort all patients that were bilaterally operated were analyzed. Risk factors for bilateral groin hernia operation as well as the relationship between groin hernia subtypes bilaterally, were analyzed using multivariate Cox proportional hazards analysis and Kappa statistics. A total of 108, 775 persons with primary groin hernia repair (89.9% males) were registered, and of those were 12,041 persons operated bilaterally (94.9% males). Females and males operated for a unilaterally direct inguinal hernia (DIH) had increased Hazard Ratios (HR) of 3.85 (CI 95% 2.14-6.19) and 4.46 (CI 95% 2.57-7.88) of being contralaterally operated for a DIH. Females and males operated for a unilaterally indirect inguinal hernia (IIH) had HRs of 6.93 (CI 95% 3.66-13.11) and 1.89 (CI95% 1.24-2.88) for being contralaterally operated for an IIH. The same tendency was seen for femoral hernias. All hernia subtypes were bilaterally associated in both genders and the hernia subtypes could be localized manifestations of generalized conditions or inheritable traits instead of localized defects.

Factors affecting hernia recurrence after Strattice mesh repair: A retrospective study

Aim The aim of the present study was to explore the factors that affect hernia recurrence after Strattice mesh repair. Patients and Methods The present study is a retrospective study of the medical records of 42 patients who underwent Strattice mesh hernia repair at Ruby Memorial Hospital, West Virginia University. Strattice mesh was employed in a variety of ventral hernia procedures, including primary ventral hernia repair, recurrent ventral incisional hernia repair, component separation (abdominal wall reconstruction), parastomal hernia repair and infected inguinal hernia repair. The main collected variables were body mass index, intraoperative hernia defect size, diabetes, wound events and steroid use. Results For 42 patients, the overall recurrence rate was 21.43 per cent. The mean body mass index (BMI) was 36.4. BMI and sex were significant risk factors for recurrence (P = 0.036, P = 0.002), respectively. The mean defect size was 97 cm2. The hernia defect size was not significantly associated with the hernia recurrence rate (P = 0.166). Of the 10 diabetics, five developed recurrence. However, diabetes was not significantly associated with the hernia recurrence rate (P = 0.726). A total of four patients (9.52 per cent) were using steroids; one developed recurrence, which was not significantly associated with the hernia recurrence rate (P = 0.20). Wound infection also was not significantly associated with recurrence (P = 0.323). Conclusions Only sex and an increase in the BMI were significantly associated with the risk of hernia recurrence. In order to decrease the modifiable risk of hernia recurrence, surgeons should counsel obese patients regarding preoperative weight loss.

Weak or Frequent Failed Peristalsis: No Difference in Outcome After Paraesophageal Hernia Repair

Introduction: Prior to the high resolution esophageal manometry Chicago classification criteria (2012), patients with “weak peristalsis” and “frequent failed peristalsis” may have been categorized as having long transition zones, ineffective esophageal motility, hypotensive peristalsis, or even as normal. Even though weak and frequent failed peristalsis are thought to be minor peristaltic abnormalities, there is little documentation of the potential effect of these findings during the performance of a traditional fundoplication. We hypothesize that patients who are categorized as having weak or frequent failed peristalsis and undergo standard paraesophageal hernia repair will experience no more dyspagia or peristaltic abnormalities on barium swallow than those patients with normal peristalsis on manometry. Methods: We performed a retrospective chart review of all patients undergoing paraesophageal hernia repair between January 2009 and December 2011. Patients were included if they had preoperative manometry and pre- and post-operative (at least 6 weeks after surgery) clinical visits and barium swallow studies. Manometry studies were re-analyzed using Chicago classification criteria and were classified as normal, weak peristalsis, frequent failed peristalsis, or other. Patients with decreased distal latency but with propagating peristalsis and esophageal shortening (n=4) were not classified as esophageal spasm, as this finding is likely due to the short esophageal length. The data were re-analyzed excluding these patients and the results were similar. Dysphagia was classified as present or absent. Barium swallow studies were classified as normal or abnormal. Barium studies with esophageal motility reported as near normal, minimally abnormal, or mildly abnormal (per the radiologist at the time of the study) were counted as normal. Results: All patients underwent primary open or laparoscopic paraesophageal hernia repair without Collis procedure or hiatal mesh mesh reinforcement. Preoperative manometry showed normal peristalsis (n=31), weak peristalsis (n=10), frequent failed peristalsis (n=9), or other. Postoperative dysphagia was noted in 2/31 (6%) of the normal group, 1/10 (10%) of the weak group, and 1/9 (11%) of the frequent failed group (p=0.87 by Chi Square analysis, p=0.61 by logistic regression). Abnormal esophageal motility seen on barium swallow occurred in 10/31 (32%) of the normal group, 1/10 (10%) of the weak group, and 3/9 (33%) of the frequent failed group (p=0.37 by Chi Square analysis, p=0.73 by logistic regression). Conclusion: Patients with weak or frequent failed peristalsis on high resolution manometry do not have any different outcome after primary paraesophageal hernia repair than those with normal manometry.

Outcomes of acute versus elective primary ventral hernia repair

The morbidity and mortality associated with acute primary ventral hernia repair have not been well described. We examined the rate of surgical site infection (SSI), hernia recurrence, and mortality in acute versus elective primary ventral hernia repair and identified predictors of morbidity and mortality after primary ventral hernia repair. A retrospective study on all patients undergoing open primary ventral hernia repair at a single institution (2000-2010) was performed. Primary outcomes were mortality at any time, SSI, and recurrence. Survival analysis for the entire, unmatched sample was conducted. We performed a risk-adjusted analysis of outcomes using two methods as follows: (1) case matching and (2) propensity score-adjusted regression model. We identified 497 patients; 57 (11%) underwent acute primary ventral hernia repair. For the entire cohort, survival was worse for patients undergoing acute repair (log rank, 0.03). Following case matching on age, body mass index, American Society of Anesthesiologists score, and hernia size, there was no difference in mortality, SSI, or recurrence. After propensity score adjustment, acute surgery was not a predictor for mortality or SSI; however, incarcerated hernias predicted recurrence. After risk adjustment, acute primary ventral hernia repair was not associated with higher mortality, infection, or recurrence compared with elective repair. Therapeutic study, level IV.

Laparoscopic Repair of Primary Ventral Hernias Does Not Decrease Hernia Recurrence Rates: A systematic Review and Meta-Analysis

Laparoscopic Repair of Primary Ventral Hernias Does Not Decrease Hernia Recurrence Rates: A systematic Review and Meta-Analysis