Recurrent Incisional Hernia Research Articles

Retroperitoneal Bronchogenic Cyst Resected by Single‐Incision Laparoscopic Surgery in an Adolescent Female: A Case Report

A 16-y-old Japanese female was referred to our hospital with a suspicion of infected retroperitoneal cyst. Abdominal CT MRI revealed a 38-mm diameter retroperitoneal cyst under the left diaphragm. Because a retroperitoneal bronchogenic cyst was suspected, total resection was planned. In addition, preoperative 3D reconstruction using multidetector CT provided a detailed location of the lesion. Based on the anatomical position, we decided that single-incision laparoscopic surgery with an anterior approach through the umbilicus would be the optimal choice. The lesion was completely resected without intraoperative complications. Histopathological examination confirmed the diagnosis of bronchogenic cyst. Postoperatively, the surgical wound became completely unnoticeable, and there was no incisional hernia or cyst recurrence at the 2-y follow-up.

Study of Laparoscopic Inguinal Hernia Repair Using an Anatomically Contoured 3D Mesh

Background: Laparoscopic inguinal hernia surgery frequently is performed with mechanical fixation of polypropylene mesh. This mechanical fixation, though is necessary to prevent mesh migration, may be associated with pain syndromes and buckling. Recently an anatomically contoured 3D mesh (developed by Dr. Philippe Pajotin) has been introduced which is made up of monofilament polypropylene and resembles normal inguinal area curvature.
 Aims and Objective: This study was conducted to know whether elimination of tacking the 3D mesh during Total extraperitoneal approach (TEP) inguinal hernia repair results in decreased postoperative pain without increasing the incidence of hernia recurrence.
 Materials and Methods: This was a prospective interventional study in which 63 patients with clinical diagnosis of inguinal hernia were included on the basis of a predefined inclusion and exclusion criteria. All selected patients underwent laparoscopic TEP inguinal hernia repair using anatomically contoured 3D mesh. Patients were assessed for postoperative pain (using visual analogue scale) during their stay in the hospital as well as in the followup period.
 Results: In this study of Lap aroscopic inguinal hernia surgery using anatomically contoured 3D mesh of 63 male patients the most common affected age group was found to be 41-50 years (25.3%) with a mean age of 47.12 years +/- 13.01. Most common inguinal hernia was of indirect type (50.7%) and was seen on right side (52.3%). Mean operative time was 113.57+/- 29.04 minutes in unilateral and 170.6 ± 5.85 minutes in bilateralinguinal hernias. Postoperative mean VAS score (12 hrs) was found to be 3.46 ± 1.51. During follow up at 1 week, 1 month and 3 months mean VAS scores were found to be 0.46 ± 0.50, 0.14 ± 0.35 and 0.01 ± 0.12 respectively. Common complications included seroma (12.6%), pneumoscrotum (7.9%) and peritoneal breech (6.3%). None of the patients developed recurrence during follow up period.
 Conclusion: An anatomically contoured mesh for laparoscopic preperitoneal hernia repair usually requires no fixation and has minimal complications. It is associated with excellent recovery and marked reduction in pain.

Comparison of the outcomes of ‘component separation with mesh’, ‘component separation without mesh’ and ‘primary prosthetic repair’ methods in complex abdominal wall reconstruction

Objectives: The aim of this study is to compare the results of different surgical methods used in giant midline incision hernias. Methods: The records of 90 patients operated on for a midline abdominal incisional hernia were reviewed retrospectively. The patients were divided into three groups based on the surgical method used primary prosthetic repair (PPR), component separation with mesh (CSM) and component separation without mesh (CS). Two-year follow-up results were compared. Results: A statistically significant difference was noted between the groups in the transverse diameter measurement of the defect (p = 0.003). Subgroup analyses revealed that the median transverse diameter was higher in the CSM group than in the CS group (p = 0.003). There was also a statistically significant difference in the duration of surgery (p < 0.001), with a subgroup analysis revealing that the duration of surgery was longer in the CSM group than in the PPR and CS groups (PPR-CSM; p = 0.008, CSM-CS; p < 0.001). Recurrent incisional hernia, smoking and postoperative morbidity development were found to be statistically and significantly associated with recurrence (p = 0.005, p = 0.002, p < 0.001; respectively). Conclusions: The use of the CSM method for the repair of giant incisional hernias may reduce recurrence.

Subcutaneous and visceral adipose tissue in patients with primary and recurrent incisional hernia

PurposeVisceral obesity rather than body mass index has been reported to be associated with a higher incidence of incisional hernias. The aim of this study was to examine the relationship between CT measured adipose tissue and muscle in primary and recurrent incisional hernia.MethodsPatients with a ‘Primary’ or ‘Recurrent incisional hernia’ were obtained from a prospective cohort of patients who were being assessed for incisional hernia repair over a 2-year period. Computerised tomography (CT)-images were analysed using NIH Image-J software to quantify adipose tissue and skeletal muscle cross-sectional areas at the level of lumber vertebra 3/4 using standard Hounsfield units. To test inter-observer ‘absolute agreement’, each parameter was measured independently by two investigators and reliability analysis performed.ResultsThirty-six patients were included in the study: 15 had a Primary while 21 had a Recurrent incisional hernia. Both groups had similar baseline characteristics. Reliability analysis for CT-measured areas showed very high interclass correlation coefficient (ICC) between observers. Patients in the recurrent group had significantly greater subcutaneous adipose tissue (SAT) [median = 321.9cm2 vs 230.9cm2, p = 0.04] and visceral adipose tissue (VAT) [median = 221.1cm2 vs 146.8cm2, p = 0.03] than those in the primary group. There was no difference in skeletal muscle areas for right [median = 2.8cm2 vs 2.9cm2] and left [median = 3.7cm2 vs 4.1cm2] rectus muscles between groups.ConclusionOur study shows that patients with a recurrent incisional hernia have significantly more subcutaneous and visceral adipose tissue than those with a primary incisional hernia. Further studies in this area are required if we are to reduce the burden of recurrent hernia following repair of a primary incisional hernia.

Early Clinical and Patient-Reported Outcomes of a New Hybrid Mesh for Incisional Hernia Repair

Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, SynecorTM, for Ventral Hernia Repair (VHR). Adult (>18 y old) patients undergoing VHR with SynecorTM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL. Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m2, respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05). Abdominal reinforcement with SynecorTM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.

A systematic review of outcome reporting in incisional hernia surgery.

BackgroundThe incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies.MethodsLiterature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included.ResultsIn total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used.ConclusionsThis review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

Perforated Appendicitis within the Sac of a Recurrent Incisional Hernia

Perforated hernial appendicitis rarely occurs with an incidence of 0.008%. We present a case of a young obese woman, a known hypertensive, who presented with abdominal pain, fever, and a tender abdominal swelling over a previous lower midline incision scar. She was thought to have a strangulated recurrent incisional hernia and was offered an emergency laparotomy. Intraoperatively, she was found to have a massive multiloculated hernia sac with the caecum, ruptured appendicitis, and abscess within a locus of the sac. Her ascending colon was mobile. The abscess was drained, appendicectomy was done, hernia repair deferred, and wound closure effected. Such atypical presentation poses a diagnostic challenge. We seek to increase awareness of this condition and contribute to the medical literature surrounding this unusual pathology.

Small bowel obstruction post-living liver transplantation.

A 59-year-old male patient with history of alcoholic cirrhosis with a MELD of 14 underwent right lobe living donor liver transplantation 4 years previously. The graft weighed 1000 g and had a single right portal vein and a single right hepatic artery that were anastomosed in an end-to-end fashion to the recipient’s right portal vein and right hepatic artery, respectively. The right anterior and right posterior bile ducts separated by >1 cm were joined together and anastomosed in an end-to-end fashion to the recipient common hepatic duct. The donor right hepatic vein was anastomosed to the orifice of the right hepatic vein and a reconstructed polytetrafluoroethylene (PTFE) graft draining the anterior sector was anastomosed to the middle hepatic vein orifice. His postoperative course was complicated by a bile leak that failed initial management with endoscopic retrograde cholangiopancreatography (ERCP) and stenting and eventually required creation of a roux en Y hepaticojejunostomy to the two separate ducts on postoperative day 23. He recovered well and was discharged to rehab. He presented a year later with a partial small bowel obstruction secondary to an incisional hernia that was initially managed conservatively and electively repaired with a mesh. He presented 4 years after transplantation with abdominal pain, nausea, and vomiting. His physical exam was significant for diffuse abdominal distension and a reducible recurrent incisional hernia. His laboratory work was notable for a mildly elevated bilirubin (3 mg/dL) and alkaline phosphatase (801 units/L). He underwent a CT scan of the abdomen and pelvis showing a small bowel obstruction (Figures 1 and 2).FIGURE 2Computed tomography of the pelvis on admissionView Large Image Figure ViewerDownload Hi-res image Download (PPT) 1What is the most likely etiology of the small bowel obstruction in this case?aAdhesive small bowel obstructionbFecal impactioncIncarcerated incisional herniadInternal herniaeIntraluminal obstruction2What is the optimal management for this patient?aExploratory laparotomy with lysis of adhesionsbExploratory laparotomy with repair of the incisional herniacExploratory laparotomy with reduction of the internal herniadExploratory laparotomy with small bowel resectioneNothing by mouth, hydration, and nasogastric decompression3Which of the following factors predisposed the patient to develop this complication?aBiliary leak and subsequent interventionsbEtiology of liver diseasecHernia repairdRejectioneUndiagnosed Crohn’s disease4What is the advantage of optimizing the venous outflow of a partial liver graft?aDecrease the risk of bile leakbDecrease the risk of graft rejectioncDecrease the risk of portal vein thrombosisdDecrease the risk of small for size syndromeeDecrease the warm ischemic time5Which of the following could potentially decrease the incidence of this complication?aAutogenous hepatic vein reconstructionbMicrovascular arterial anastomosiscPlacing drainsdPortal vein interposition grafteUsing a smaller liver graft

Incisional Hernia Incidence, Repair Techniques, and Outcomes Based on 1600 Consecutive Patients Receiving Abdominally Based Autologous Breast Reconstruction.

As the number of postmastectomy patients who receive abdominally based autologous breast reconstruction (ABABR) increases, the frequency of unique paramedian incisional hernias (IHs) at the donor site is increasing as well. We assessed incidence, repair techniques, and outcomes to determine the optimal treatment for this morbid condition. A total of 1600 consecutive patients who underwent ABABR at the University of Pennsylvania between January 1, 2009, and August 31, 2016, were retrospectively identified. Preoperative and operative information was collected for these patients. Incisional hernia incidence was determined by flap type and donor site closure technique. Repair techniques and postoperative outcomes for all patients receiving IH repair (IHR) after ABABR at our institution were also determined. Univariate and multivariate analyses were conducted. The incidence of IH after ABABR in our health system was 3.6% (n = 61). Fifteen additional patients were referred from outside hospitals for a total of 76 patients who received IHR. At the time of IHR, mesh was used in 79% (n = 60) of cases (13 biologic and 47 synthetic), with synthetics having significantly lower recurrent IH incidence (10.6% vs 38.5%, P = 0.017) when compared with biologics. Mesh position did not have any statistically significant effect on outcomes; however, sublay mesh position had zero adverse outcomes. Mesh should be used in all cases when possible. Although retrorectus repair with mesh is optimal, this plane is often nonexistent or too scarred in after ABABR. Thus, intraperitoneal underlay mesh with primary fascial closure or primary closure with onlay mesh placement should then be considered.

A case report of a rare case of uterine fibroid herniating as recurrent incisional hernia

Uterine leiomyoma is the most common estrogen-dependent benign tumor of the uterus. Approximately 5–20% occur in the reproductive age group. It is composed of smooth muscle and fibrous tissue. Asymptomatic myomas present in 50% of cases. The incisional hernia develops in the scar of a surgical incision. We are presenting a case of fibroid uterus with recurrent incisional hernia in a 51-year-old, morbidly obese female patient with swelling over the midline of the abdomen for 3 years. The patient was a second para patient with a history of one cesarean delivery 24 years ago followed by one normal delivery 18 years ago. The patient has a history of incisional hernia meshplasty 12 years ago. She was subjected to ultrasound and magnetic resonance imaging abdomen with pelvis which confirmed fibroid uterus herniating as a recurrent incisional hernia. Management of the case is discussed.

Recurrent incisional hernia repairs at a tertiary hernia center: Are outcomes really inferior to initial repairs?

BackgroundRecurrent ventral hernia repairs are reported to have higher recurrence and complication rates than initial ventral hernia repairs. This is the largest analysis of outcomes for initial versus recurrent open ventral hernia repairs reported in the literature. MethodsA prospective, institutional database at a tertiary hernia center was queried for patients undergoing open ventral hernia repairs with complete fascial closure and synthetic mesh placement. ResultsA total of 1,694 open ventral hernia repairs patients were identified, including 896 (52.9%) initial ventral hernia repairs and 798 (47.1%)recurrent ventral hernia repairs. Recurrent ventral hernia repair patients were more complex: older (P = .003), higher body mass index (P < .001), higher American Society of Anesthesiologists class (P < .001), incidence of diabetics (P = .003), comorbidities (P < .001), and larger hernia defects (133.3 ± 171.9 vs 220.2 ± 210.0; P < .001). Recurrent ventral hernia repairs also had longer operative times (161.6 ± 82.4 vs 188.2 ± 68.9 minutes; P < .001), increased use of preoperative botulinum toxin A injection (4.3% vs 10.1%; P = .01), components separation (19.2% vs 39.5%; P < .001), and panniculectomy (20.3% vs 35.8%; P < .001). The overall hernia recurrence rate was 4.4% at a mean follow-up of 36.6 ± 45.5 months. Between the initial ventral hernia repairs and recurrent ventral hernia repairs, the hernia recurrence rates were equivalent (4.2% vs 4.7%, P = .63). Rates of wound infection, seromas, hematomas, mesh infections, and wound related reoperations (P > .05) were nonsignificant. ConclusionAt a tertiary hernia center, despite higher-risk patients, larger hernia defects, and increased components separation in recurrent ventral hernia repairs, early recurrence rates, wound complications, and reoperations are similar to initial ventral hernia repairs.

Recurrent incisional hernia repair: surgical outcomes in correlation with body-mass index.

Hernia recurrence rates after incisional hernia repair vary between 8.7 and 32%, depending on multiple factors such as patient characteristics, the use of meshes, surgical technique and the degree of experience of the treating surgeon. Recurrent hernias are considered complex wall hernias, and 20% of all incisional hernia repairs involve a recurrent hernia. The aim of this study was to investigate the outcomes after recurrent incisional hernia repair, in association with surgical technique and body-mass index (BMI). All patients who had incisional hernia repair between 2013 and 2018 were included. Primary outcome was rate of recurrent incisional hernia after initial hernia repair. Secondary outcomes were complication rate and recurrence rate in association with BMI. A number of 269 patients were included, of which 75 patients (27.9%) with a recurrent incisional hernia. Recurrent hernia repair was performed in 49 patients, 83.7% underwent open repair. Complication rate for recurrent hernia repair was higher than for the initial incisional hernia repair. Of the 49 patients with recurrent hernia repair, patients with a BMI above 30 had higher complication and recurrence rates compared to patients with BMI below 30. Especially infectious complications were more common in patients with a higher BMI: 23.1% vs. 0% wound infections. The results from this study show that complication and recurrence rates are increased after recurrent incisional hernia repair, which are further increased by obesity. Only a limited amount of literature is available on this topic, further larger multicenter studies are necessary, until then a patient-specific surgical approach based on the surgeon's expertise is recommended.

Is it safe to combine ventral hernia repair with bariatric surgery?

Obesity is one of the important precipitating factors for primary and incisional ventral hernias. There is controversy regarding the optimal time and method of repair of abdominal wall hernias in patients undergoing bariatric surgery. We reviewed our series of 250 patients who underwent bariatric surgery over 6 years period. 7 morbidly obese patients undergoing bariatric surgery had simultaneous ventral hernia repair. Roux-en-Y gastric bypass (RYGB) in 2 patients and laparoscopic sleeve gastrectomy (LSG) were done in 5 patients. 6 patients had primary midline paraumbilical hernia and 1 patient had large recurrent incisional hernia. Open intraperitoneal onlay mesh (IPOM) repair was done in 5 cases with hernia defect &lt;5 cm. Sutured repair was done in 1 patient, recurrence occurred after 3 months. IPOM repair was done 6 months later after significant weight loss. 1 patient of large incisional hernia (10 cm defect) with cholelithiasis underwent open mesh hernioplasty and panniculectomy. Postoperative seroma occurred in one patient, it subsided after repeated aspirations. After average follow up of over 2 years there has been no recurrence.

Analysis of 4,015 recurrent incisional hernia repairs from the Herniamed registry: risk factors and outcomes.

The proportion of recurrences in the total collective of all incisional hernias has been reported to be around 25%. In the European Hernia Society (EHS) classification, recurrent incisional hernias are assigned to a unique prognostic group and considered as complex abdominal wall hernias. Surgical repairs are characterized by dense adhesions, flawed anatomical planes caused by previous dissection or mesh use, and device-related complications. To date, only relatively small case series have been published focusing on outcomes following recurrent incisional hernia repair. This cohort study now analyzes the outcome of recurrent incisional hernia repair assessing potential risk factors based on data from the Herniamed registry. Special attention is paid to the technique used during the primary incisional hernia repair, since laparoscopic IPOM was recently deemed to cause more complications during subsequent repairs. In the multicenter Internet-based Herniamed registry, patients with recurrent incisional hernia repair between September 2009 and January 2018 were enrolled. In a confirmatory multivariable analysis, factors potentially associated with the outcome parameters (intraoperative, postoperative and general complications,complication-related reoperations, re-recurrences, pain at rest and on exertion, and chronic pain requiring treatment at one-year follow-up) were evaluated. In total, 4015 patients from 712 participating hospitals were included. Postoperative complications and complication-related reoperations were significantly associated with larger recurrent hernia defect size, open recurrent incisional hernia repair and the use of larger meshes. General complications were more frequent in female sex patients and when larger meshes were used. Higher re-recurrence rate was observed with lateral defect localization, present risk factors, and time interval ≤ 1year between primary and recurrent incisional hernia repair. Pain rates at 1-year follow-up were unfavorably related with pre-existing preoperative pain, female sex, lateral defect localization, larger mesh, presence of risk factors, and postoperative complications. As regards the primary incisional hernia repair technique, laparoscopic IPOM was found to show no effect versus open mesh techniques on the subsequent recurrence repair, despite a trend toward higher rates of complication-related reoperations. The outcomes of recurrent incisional hernia repair were significantly associated with potential influencing factors, which are very similar to the factors seen in primary incisional hernia repair. The impact of the primary incisional hernia repair technique, namely laparoscopic IPOM versus open mesh techniques, on the outcome of recurrent incisional hernia repair seems less pronounced than anticipated.

Preventing Hernia Recurrence: Optimising Mesh Use in Incisional Hernia Repair

Incisional hernia is a common complication of abdominal surgery, affecting up to a quarter of patients undergoing laparotomy. This case report discusses a 72-year-old lady with a recurrent incisional hernia following an emergency Hartman’s procedure. The discussion covers the properties of synthetic vs biological meshes, the significance of the anatomical location of the mesh, fixation methods, laparoscopic surgery, short and long term complications.&#x0D; Key points:&#x0D; &#x0D; The ideal mesh is biocompatible, strong, resistant to infection, has minimal bioreactivity and non-immunogenic&#x0D; Pore size is important to the degree of mesh integration, infection risk and the development of chronic pain&#x0D; Synthetic mesh is useful in contaminated cases but adds a significant cost to the procedure&#x0D; Sublay mesh placement is associated with a reduced risk of recurrence&#x0D; Most recurrences occur at the edge of the mesh. Surgeons should ensure a 5cm overlap between the mesh and native tissues and consider dual fixation methods&#x0D; Laparoscopic hernia repair has been associated with a shorter post-op recovery, less pain and a short term reduced risk of recurrence, however there is a greater risk of bowel injury and development of adhesions&#x0D; Composite meshes can reduce the risk of adhesions with intraperitoneal mesh placement&#x0D; Chronic pain is associated with the use of tacks, heavy weight synthetic meshes and chronic infection&#x0D; Resorbable meshes have not been shown to reduce chronic pain&#x0D; The choice of mesh, method of repair and surgical approach should be individualised to the patient.&#x0D;

A challenging solution to a complex incisional hernia – a video vignette

We present the case of a 76 year old male, whose surgical history included a laparoscopic left hemicolectomy for colon cancer, complicated with anastomotic leakage and multiple interventions for recurrent paraostomal and midline incisional hernias, one of them resulting in intestinal perforation. Secondary wound closure with negative wound pressure therapy and skin grafts had to be applied. The patient was referred to our center as a result of a complex M1-2-3-4-5 W3 (1) incisional hernia with deep skin ulcerations and intestinal exposure.

One-Year Health Care Utilization and Recurrence After Incisional Hernia Repair in the United States: A Population-Based Study Using the Nationwide Readmission Database

BackgroundMost data on health care utilization after incisional hernia (IH) repair are limited to 30-days and are not nationally representative. We sought to describe nationwide 1-year readmission burden after IH repair (IHR). MethodsPatients undergoing elective IHR discharged alive were identified using the 2010-2014 Nationwide Readmission Database. Transfers and incomplete follow-up were excluded. Descriptive statistics were used to describe rates of 1-year readmission, IH recurrence, and bowel obstruction. Cox regression allowed identification of factors associated with 1-year readmissions. Generalized linear models were used to estimate predicted mean difference in cumulative costs/year, which allowed estimation of IHR readmission costs/year nationwide. ResultsOf 15,935 identified patients, 19.35% were readmitted within 1 y. Patients who were readmitted differed by insurance, Charlson index, illness severity, smoking status, disposition, and surgical approach compared with those who were not (P < 0.05). Of readmitted patients, 39.3% returned within 30 d; 50.9% and 25.6% were due to any and infectious complications, respectively; 25.6% presented to a different hospital; 35.4% required reoperation; 5.4% experienced bowel obstruction; and 5% had IHR revision. Factors associated with readmissions included Medicare (hazard ratio [HR] 1.46 [95% confidence interval 1.19-1.8]; P < 0.01) or Medicaid (HR 1.42 [1.12-1.8], P < 0.01); chronic pulmonary disease (1.38 [1.17-1.64], P < 0.01), and anemia (1.36, [1.05-1.75], P = 0.02). Readmitted patients had higher 1-year cumulative costs (predicted mean difference $12,190 [95% CI: 10,941-13,438]; P < 0.01). Nationwide cost related to readmissions totaled $90,196,248/y. ConclusionsOne-year readmissions after IHR are prevalent and most commonly due to postoperative complications, especially infections. One-third of readmitted patients require a subsequent operation, and 5% experience IH recurrence, intensifying the burden to patients and on the health care system.

Application of computed tomography and abdominal pressure measurement in the treatment of giant incisional hernias

Introduction: Giant abdominal wall defects represent a major challenge for surgeons. CT scan can determine the ratio between the volume of the hernia sac and the abdominal cavity, determining the extent of the disproportion, which is related to the postoperative abdominal pressure value. Aim: Confirmation of the significance of CT examination in postoperative giant abdominal wall defects, effectiveness analysis of the reconstruction method by abdominal pressure measurement. Method: A prospective study is conducted on patients with giant incisional hernias, with preoperatively performed abdominal CT scan. Tension-free abdominal wall reconstruction is realized with retromuscular Prolene mesh and hernial sac. Abdominal pressure is measured during and after surgery. Patients' follow-up is performed through phone after 2-4-6 months. Results: We present our results through three cases. First case: 48-year-old woman presented a giant recurrent incisional hernia and multiple comorbidities. Maximum defect diameter was: 155 mm, hernia volume: 1536.63 cm3, BMI = 43.6. The patient was discharged after seven days. Second case: 51-year-old male patient presented with multilocular giant incisional hernia, BMI = 26,85. Maximum diameter of the two wall defects were 123 mm and 105 mm, their total volume: 406.41cm3. The patient was discharged after five days. Third case: A 67-year-old male patient presented with giant incisional hernia. The abdominal defect size was 100/100 mm (LL/CC), volume: 258.10 cm3, BMI = 23.7. The patient was discharged after four days. Conclusion: The proper surgical technique can be established based on the preoperative CT scan. Abdominal wall reconstruction with retromuscular Prolene mesh and hernial sac provides a cheap, reliable, tension-free technique. The technique's short-term efficacy can be determined by abdominal pressure measuring through the bladder. Orv Hetil. 2020; 161(9): 347-353.

Implantation of biologic mesh in ventral hernia repair-does it make sense?

Biological acellular porcine dermis mesh, such as Permacol™, has been used since 2009 to treat abdominal incisional hernias in a septic context. This study investigated the risk factors for incisional hernia recurrence after biological mesh augmentation. Over a period of 6years from February 2009 to February 2015, 68 patients underwent surgery. The mesh was placed intraperitoneally with closure of the anterior fascia in 27 cases (39.7%). The biological mesh was placed in the retromuscular pre-fascial plane in 1 case (1.5%) and pre-aponeurotic plane in 1 case (1.5%). Closure of the anterior fascia was not achieved in 39 cases, including 20 cases in which the mesh was placed intraperitoneally (intraperitoneal bridging group, 29.4%) and 19 cases in which the mesh was placed between the edges of the fascia (inlay bridging group, 27.9%). There were 37 cases of postoperative surgical site infections (54.4%), and Clavien-Dindo morbidity staging indicated stage I-II and III-IV complications in 19.1% and 44.1% of the cases, respectively. The recurrence rate was 61.8%, and the mortality rate was 0%. The rate of recurrence was significantly lower in the «fascia approximated» group (37%), p = 0.001). Univariate analyses of risk factors for procedural failure indicated an increased risk of recurrence in cases of postoperative surgical site infections, complications of Clavien-Dindo grade III or higher, an absent fascial closure in front of the mesh (OR = 8.69), an operating time longer than 180min, and a VHWG score higher than 2. After logistic regression, the risk factors for recurrence were postoperative infections (OR = 6.2), placement of bridged biological mesh (OR = 22.3), and postoperative morbidity grade III or higher (OR = 16.7). Patients with postoperative surgical site infections are at an increased risk for recurrence, and bridged mesh placements lack efficacy. Overall, this study challenges the purported advantage of biologics in treating incisional hernia repairs.

Dermo-Peritoneal Flap: a Novel, Safe and Effective Technique to Manage Abdominal Defects in Complicated Recurrent Incisional Hernia

Recurrences after open surgical or laparoscopic repair of abdominal wall defects are not uncommon. No technique is the “best” solution, and a wide variety of surgical options are being used by surgeons for specific defects or locations with variable results. We describe a new technique “dermo-peritoneal flap,” which can easily be used to manage such difficult incisional hernias. Three patients having difficult recurrent incisional hernia were operated from April 2014 to May 2016 using the “dermo-peritoneal flap” technique. Detailed pre-operative assessment was done by structured questionnaire and ultrasonography (USG) scan to rule out co-existing intra-abdominal pathology and subacute/blind loop obstruction. Also, the approximate size and location of defect were estimated clinically and confirmed by pre-operative USG scan. A vertical ellipse in midline was marked, and the area was de-epithelialized. Bilateral abdominal flaps were elevated, leaving the de-epithelized dermo-fat patch over sac. After reaching the defect, blunt separation of the sac was done from edges of the defect. The sac was reduced into the abdominal cavity without opening. Edges of dermal tissue were sutured to edges of the defect. Onlay prolene mesh-plasty was done, and abdomen was closed with suction drains. Patients were aged 48, 52, and 57 years, and all patients were women. The patients had undergone 6, 5, and 6 surgeries, and duration of hernia was 6, 6.5, and 4.5 years respectively. Two of the patients had undergone resection anastomosis of gangrenous bowel previously. All patients have shown no signs of recurrence. Mild discharge from the suture line was seen in two patients, which resolved spontaneously on dressings. One of them has developed a midline scar similar to natural umbilicus. The concept of de-epithelialization of thinned-out skin over sac makes surgery easier and safe and also provides tough and vascular tissue which plugs the defect. It can also be used universally with any technique of repair for any location and size of defect. This is a case series of 3 lady patients, all of whom had ventral/incisional hernias operated earlier by this new technique of isolated de-epithelialized overlying skin used as a flap strengthened with overlay mesh.