Repair Of Complex Incisional Hernias Research Articles

Early outcomes of open anterior versus posterior components separation with transversus abdominis release for large median incisional hernias: a retrospective stepwise analysis.

Complex incisional hernia is still a debatable topic, with increasing incidence and an increased local and systemic postoperative morbidity and mortality. The size of the defect is a risk factor for both difficult closure and 30-day readmission due to complications. The main option for closure such defect is a mesh augmented component separation technique. The goal was to evaluate 30-day wound events and general complications including 90days mortality. We present a retrospective study that includes patients from two different university hospitals who underwent open incisional hernia repair with anterior component or posterior component separation between January 2015 and December 2021. Only non-contaminated adult patients (over 18years old) with postoperative primary or recurrent median abdominal wall defects larger than 6cm and with complete fascial closure were included. Demographics (age, gender, Body Mass Index-BMI, American Society of Anesthesiologists Classification-ASA score), recurrence rank, and co-morbidities), operative details, patient outcomes complications were collected. A native abdomen/pelvis computerized tomography (CT) scan was performed preoperatively in all patients and the anatomy of the defect and volumetry (abdominal cavity volume, incisional hernia volume and peritoneal volume) were evaluated. One of the component separation technique was performed according to Carbonell's equation. Two hundred and two patients (101 from each group) were included. The patients with posterior component separation were more comorbid and with larger defects. The procedure was longer with 80min but overall length of hospital stay shorter (p < 0.001) for posterior component separation. Seroma, hematoma and skin necrosis were equally distributed for both group of patients and there was no direct relation to surgery (OR 0.887, 95% CI 0.370-2.125, p = 0.788; OR 1.50, 95% CI 0.677-3.33, p = 0.318 and OR 0.386, 95% CI 0.117-1.276, p = 0.119). Surgical Site Infection rate was increased for anterior component separation (p =0.004). Complex incisional hernia repair is a challenge given by a large amount of wound complications. Choosing between anterior and posterior component separation is still a source of significant debate. We were not able to depict significant different rates of complications between the procedures and we couldn't find any specific factor related to complications.

OC-011 SARCOPENIA IN COMPLEX ABDOMINAL WALL SURGERY: IMPACT ON THE POSTOPERATIVE COMPLICATIONS

Abstract Aim Sarcopenia is defined as the skeletal muscle mass loss and is considered as a prognostic factor in oncological surgical patients, liver transplant and trauma surgery. It can be reversed with exercise and diet. Nonetheless there is a lack of evidence of its impact on complex abdominal wall surgery. The aim is to evaluate the impact of sarcopenia in postoperative complications after complex incisional hernia repair. Material and Methods Retrospective study of patients undergoing surgery for complex incisional hernias &amp;gt;10cm (W3 of European Hernia Society classification) between 2014–2021. Sarcopenia was stablished as the skeletal muscle index (SMI), measured at L3 transversal section of a preoperative CT-scan. Previously defined literature-based SMI cutoff values were used: men &amp;lt;52,4cm2/m2, women &amp;lt;38,5cm2/m2. Results We included 105 patients, of which 29 (27,6%) were sarcopenic. The mean follow-up was 24,11 (19,28) months. The mean age and body mass index was 65,34 (10,98) and 31,85 (5,55), respectively. Sarcopenia was significantly associated with a higher risk of death [OR 11,21 (IC95% 2,76–45,52); p=0,001]. We observed a difference in need of intensive care unit (ICU) stay [OR 2,24 (IC95% 0,88–5,69); p=0,089] and cardiac complications [OR 2,96 (IC95% 0,79–11,11); p=0,108], not reaching statistical significance. Differences in surgical site occurrence or infection were not observed. After analysing by possible cofounding factors (age, comorbidities, ICU stay), sarcopenia remains associated with a higher risk of death [OR 9,08 (IC95% 2,08–39,59); p=0,003]. Conclusions Given the results of our study sarcopenia might increase the risk of death, independent of age, comorbidities and ICU stay.

Dumanian Technique for Repair of Complex Incisional Hernias

Incisional hernia is protrusion of tissue at or near the site of an incision from a previous surgery. It is a challenging procedure to repair complex incisional hernias. Most of the numerous reconstructive techniques are unable to achieve goals of hernioplasty owing to various factors being planar mesh impose the risk of pain and infection whereas conventional suture repairs can fail due to suture pull through, rupture or slipping of knot. The open components separation technique (CST) creates large undermining skin flaps especially useful in patients with complex hernias who require judicial approximation of the midline fascia. Another novel technique for repair of such hernias is the Dumanian Technique : using mesh as a suture material and has been shown to improve the ultimate tensile strength (UTS) and thus prevent surgical failure. Both the techniques are implemented in our case to achieve successful abdominal closure.

OC-024 MINIMALLY INVASIVE TREATMENT OF COMPLEX INCISIONAL/VENTRAL HERNIAS USING BOTULINUM TOXIN COMBINED WITH ROBOTIC SURGERY: ROBOTOX PROTOCOL

Abstract Introduction Incisional/ventral hernia repair has changed in the last 20 years. Posterior component separation like TAR (transversus abdominis muscle release) has increased as a revolutionary technique. On the other hand, the use of botulinum toxin (BT) has allowed better closure defect with no tension. We present a preliminary original protocol named ROBOTOX for complex incisional /ventral hernia repair that combined BT and robotic surgery to minimize the TAR procedure. Material and methods BT (Dysport®) was administered in patients with a complex incisional hernia repair and a transverse defect ≧8cm one month before robotic surgery. Demographic variables (age, sex, BMI), EHS classification, need of TAR, size transverse defect, postoperative complications and recurrence were studied. All patients had a previous CT scan. Results Five patients were included in ROBOTOX protocol, 3 men and 2 women with a median age of 63±8, median BMI of 32±3. Four patients had a M3W3 and one a L3 W2 hernia. Median size defect of 11,2±2. Three of them only needed Rives technique, one a unilateral TAR and one a 5 cm dissection of bilateral TAR. At the moment, with a FU of 6±2 months, no recurrences have been reported. Conclusions Robotic surgery combined with BT would allow a downstaging treatment in patients with complex incisional/ventral hernias. A major cases and long term follow up is needed to better conclusions.

P-148 EFFECT OF MEDICAL AND SURGICAL WEIGHT MANAGEMENT PROGRAMMES FOR PRE-OPERATIVE WEIGHT LOSS PRIOR TO VENTRAL HERNIA REPAIR

Abstract Introduction Obesity is a recognised risk factor for perioperative morbidity in patients undergoing complex incisional hernia repair. Weight reduction can reduce risk of perioperative complications. The aim of this study was to assess the effects of the different weight management modalities prior to planned incisional hernia repair upon the Carolinas equation for Determining Associated Risks (CeDAR) score. Method A prospectively maintained database of patients who were referred to the weight management clinic prior to planned incisional hernia repair was reviewed. Patients’ demographics, weight loss outcomes and CeDAR scores were calculated before and after the intervention. Results 9 patients were enrolled onto the weight management programme prior to the planned incisional hernia repair (defect size 4 – 14cm), 3 underwent bariatric surgery whilst 6 had medical weight management in the form of a 12-week pre-operative diet programme. The mean age was 54 ± 9.4 years with a mean weight pre-intervention of 110.5 ± 7.4 kg and the mean BMI was 41.78 ± 1.98 kg/m2. Bariatric surgery was associated with a higher percentage weight loss (22.6%) compared to 12week diet programme (10.4%) with an associated higher reduction of CeDAR score (14% and 4% reduction in risk respectively). Conclusion Formal weight management programmes prior to complex abdominal wall reconstruction leads to clinically significant weight loss with reduced CeDAR score. Patients with raised BMI considering incisional hernia repair should be counselled for this and where possible offered a suitable weight management to reduce peri-operative risk.

P026 PREOPERATIVE ABDOMINAL WALL RELAXATION WITH BOLULINUM TOXIN A INJECTION CAN FACILITATE SURGICAL REPAIR OF INCISIONAL HERNIAS: LONG-TERM SINGLE CENTER FOLLOW-UP OF 12 PATIENTS

Abstract Aim It was investigated how preoperative botox injection in the abdominal musculature both facilitates the surgical repair of incisional hernias and reduce the rate of hernia recurrence. Material and Methods Botulinum toxin A injections was given to 12 patients (7 female and 5 male) suffering from complex incisional wall hernia, 4 to 6 weeks preoperatively. Mean age was 54 years. 9 patients were treated by anterior and/or posterior component separation repair and 3 by Rives-Stoppa repair. By all patients the mesh could be placed in the retromuscular position. No bridging was necessary. Results After a follow-up of 3 to 4 years we examined the patients clinically and by sonography. The rate of incisional hernia recurrence was low as well as the rate of side effects like chronic pain, persisting paresthesia and mobility disorders of the abdomen. Conclusions Preoperative injection of botulinum toxin A can help to reduce the risk of further hernia recurrence after surgical repair of complex incisional hernias of the abdominal wall.

External and internal oblique abdominis muscle release (eimr) for complex incisional hernia repair: Modification of partition surgical technique

Incisional hernia is the name given to hernias that form in the incision site after abdominal operations. The only treatment option for incisional hernias is surgery and the repair of incisional hernias is still a serious issue for surgeons. The aim of this study is to present an alternative surgical treatment procedure for the treatment of incisional hernias. The study included patients who were diagnosed with complex incisional hernia and underwent surgery between November 2016 and December 2017. In addition to demographic data such as age and gender, the operative and postoperative morbidity and mortality rates were documented. The patients who underwent additional surgical procedure other than herniography were excluded from the study. The study included 16 patients who met the inclusion criteria. Of 16 patients, nine (56.25%) were male and seven (43.75%) were female. The mean age of the patients was 51.25 years and the mean body mass index was 25.3 kg/m2. The hernia size measured in the computed tomography was 11.01 cm on average in men and 11.56 cm on average in women. The intravesical pressure measured intraoperatively before the surgery was 3.4 mmHg on average. While the mean intravesical pressure was found as 12.25 mmHg after the abdomen was closed, the mean intravesical pressure was measured as 6.43 mmHg after the relaxation incision and graft installment. The duration of the surgery was 48 minutes on average. In the postoperative period, paralytic ileus responsive to treatment was observed in two patients and skin necrosis was observed in one patient. No pulmonary embolism, respiratory problems and compartment syndrome that may cause mortality developed in patients. No recurrence was observed in patients in the control one year after the surgery. The golden standard surgical method for the incisional hernia surgery has yet to be determined. There is still a need for prospective randomized studies. We believe that our technique can be an alternative to other techniques in the incisional hernia surgery due to its easy applicability and low rate of complications.

The influence of Transversus Abdominis Muscle Release (TAR) for complex incisional hernia repair on the intraabdominal pressure and pulmonary function.

IntroductionAmong many other techniques for Abdominal Wall Reconstruction (AWR), posterior component separation with Transversus Abdominis Release (TAR), continues to gain popularity and it is increasingly used with promising long-term results. Our goal was to evaluate the influence of TAR with mesh retromuscular reinforcement on the intra-abdominal pressure (IAP) and respiratory function in a series of patients with complex incisional hernias (IH).MethodsSince November 2014 through February 2019, patients with TAR were identified in the Clinical Department of Surgery database and were retrospectively reviewed. Outcome measures include: demographics, pre- and perioperative details, preoperative and postoperative IAP and plateau pressure (PP).ResultsOne-hundred-and-one consecutive TAR procedures (19.7% from all incisional hernia repairs) were analyzed. Mean age was 63 years with a mean Body Mass Index (BMI) of 31.85 kg/m2 (25–51). Diabetes and Chronic Obstructive Pulmonary Disease (COPD) were the main major comorbidities. Mean hernia defect area was 247 cm2 (104–528 cm2).ConclusionTAR is a safe and sound procedure with acceptable modifications of the IAP morbidity and recurrence rate when correctly performed on the right patient.

What results can be expected one year after complex incisional hernia repair with biosynthetic mesh?

Incisional hernia is a frequent complication after midline laparotomy. The current standard repair includes the use of a synthetic mesh to prevent recurrence. However, the use of a synthetic mesh in a contaminated field carries a higher risk of mesh infection. In this setting biologic and biosynthetic meshes can be used as they resist to infection, but these are absorbable meshes. This raises the question of the risk of recurrence as the mesh disappears. Phasix® is a biosynthetic mesh getting absorbed in 12-18 months. The aim of this study was to assess the 1-year recurrence rate after abdominal-wall repair with a Phasix® mesh. All patients undergoing ventral hernia repair between 2016 and 2018 at the University Hospital of Dijon using a Phasix® mesh were prospectively included in a database. They were all followed-up with a physical exam and a routine CT scan at one year. All postoperative complications were recorded. Twenty-nine patients were included in the study (55.2% women), with a mean BMI of 30,25kg/m2. Nineteen meshes were sublay and 10 intraperitoneal. Complications at 1 month were mainly mild: Clavien-Dindo I and II (61.1%). No mesh was explanted. There was no chronic infection. The mean length of stay was 11.5 days. The 1-year recurrence rate was 10.3%. Patients having undergone complex ventral hernia repair with a Phasix® mesh have a 1-year recurrence rate of 10.3%. No severe surgical site occurrence was detected. A longer follow-up in a larger number of patients could confirm the place of this mesh in abdominal-wall repair.

Comparing the outcomes of external oblique and transversus abdominus release using the AHSQC database.

Myofascial release techniques at the time of complex hernia repair allow for tension-free closure of the midline fascia. Two common techniques are the open external oblique release (EOR) and the transversus abdominis release (TAR). Each technique has its reported advantages and disadvantages, but there have been few comparative studies. The purpose of this project was to compare the outcomes of these two myofascial release techniques. The Americas Hernia Society Quality Collaborative (AHSQC) database was queried and produced a data set on 24 May 2018. All patients undergoing open incision hernia repair with an open EOR or TAR were evaluated, and outcomes were compared including hernia recurrence, quality of life, and 30-day wound-related complications. 3610 patients met the inclusion criteria of undergoing open incisional hernia repair (501 undergoing EOR and 3109 undergoing TAR). Seventy surgeons from 50 institutions contributed EOR patients, and 124 surgeons from 89 institutions contributed TAR patients with no differences between the two groups in surgeons' affiliation. Comparing open EOR and TAR showed no significant differences in hernia recurrence, quality of life, or 30-day surgical site infection rate. EOR had a significantly higher rate of surgical site occurrences compared with TAR (p < 0.05); however, this did not result in an increase in surgical site occurrences requiring procedural interventions. Equivalent outcomes were achieved using the EOR or TAR techniques in the open repair of incisional hernias. Both techniques offer consistently good outcomes and are important adjuncts in the repair of complex incisional hernias.

Simultaneous Complex Incisional Hernia Repair and Bariatric Surgery for Obese Patients: a Case Series of a Single-Center Early Experience.

Obesity is associated with recurrence of complex incisional hernia repair (CIHR). Bariatric procedure during CIHR can improve recurrence rates without increasing morbidity. This study aimed to describe our results after CIHR in patients with obesity, in which a simultaneous bariatric procedure was performed. We performed a retrospective observational study including patients who underwent surgery between January 2014 and December 2018, with a complex incisional hernia (CIH) according to the Slater classification and body mass index (BMI) ≥35. CIHR was the main indication for surgery. We collected demographic data, comorbidities, CIH classification according to the European Hernia Society, type of bariatric procedure, postoperative morbidity using the Dindo-Clavien classification, and short-term results. Computed tomography (CT) is performed preoperatively. Ten patients were included in the study (7 women). The mean BMI was 43.63±4.91 kg/m2. The size of the abdominal wall defect on CT was 8.86±3.93 cm. According to the European Hernia Society classification, all CIHs were W2 or higher. Prosthetic repair of the CIH was selected. Onlay, sublay, preperitoneal, and inlay mesh placement were performed twice each, as well as one modified component separation technique and one transversus abdominis release. Gastric leak after sleeve gastrectomy was the only major complication. Short-term outcomes included one recurrence, and % total weight loss was 24.04±8.03 after 1-year follow-up. The association of bariatric procedures during CIHR seems to be feasible, safe, and could be an option for surgical treatment in selected patients.

Comparison of Hernia Recurrence and Seroma Formation in Cancer Patients Undergoing Incisional Hernia Repair with Transfascial Sutures vs. Fibrin Glue for Mesh Fixation

Background: Open ventral incisional hernia repairs with mesh reduce hernia recurrence rates to less than 10%. The Rives-Stoppa retrorectus hernia repair technique is becoming the standard of care for mesh repair of complex incisional hernias. In these hernia repairs, mesh has traditionally been fixated with transfascial sutures, but fibrin glue has been used as an alternative to reduce pain and may also reduce operative time and the risk of seroma formation. The primary objective of this study was to compare the rates of hernia recurrence and seroma formation in cancer patients who underwent Rives-Stoppa incisional hernia repair using transfascial sutures vs. fibrin glue for mesh fixation. Methods: We conducted a retrospective review of a prospectively maintained database of cancer patients at our free-standing cancer institution who underwent Rives-Stoppa ventral incisional hernia repair performed at our institution. Fisher’s exact test was used to assess differences in hernia recurrence and seroma formation rates between patients who underwent mesh fixation with transfascial sutures vs. fibrin glue. Using a neutral prior probability distribution, a Bayesian analysis was performed to evaluate the posterior probability of seroma formation requiring intervention and hernia recurrence after retrorectus repair with fibrin glue fixation. Log-rank test was used to assess the difference in overall survival between the two groups. Results: Forty-one patients (22 in the transfascial suture group and 19 in the fibrin glue group) were included in the analysis. The patient demographics were similar in both groups. There was no statistically significant difference in seroma formation requiring drainage by interventional radiology (IR) between the fibrin glue and the transfascial suture groups (5.3% vs. 9.1%; P=1.00). The odds of having a hernia recurrence was 4 times higher in the transfascial suture group than in the fibrin glue fixation group, but this was not statistically significant (18.2% vs 5.3%, p=0.35). The Bayesian analysis showed a 90% probability that the hernia recurrence rate would be higher in the transfascial suture than in the fibrin glue fixation group. Conclusion: Using fibrin glue instead of transfascial sutures may reduce hernia recurrences and seroma formation in cancer patients undergoing ventral incisional hernia repairs with retro rectus mesh. The high probability of reducing the odds of hernia recurrence with fibrin glue fixation warrants a prospective randomized, multi-institutional clinical trial.

Abdominoplasty and complex incisional hernia repair performed in the same surgery by abdominal wall surgeon

Abdominoplasty and complex incisional hernia repair performed in the same surgery by abdominal wall surgeon

Surgical “error traps” of open posterior component separation—transversus abdominis release

Past techniques for the repair of complex incisional hernias have been met with unacceptably high recurrence rates and postoperative complications. The transversus abdominis release (TAR) is a versatile and durable solution gaining popularity amongst both abdominal wall specialists and general surgeons. However, several preoperative factors and specific intraoperative pitfalls can have a major impact on patient outcomes. The authors review the current literature and draw upon their own practice experience to highlight key preoperative and perioperative steps for avoiding common pitfalls or "error traps" often performed by a surgeon new to this surgical technique. We discuss preoperative factors that influence the outcomes of patients undergoing incisional hernia repair. We show how a TAR that preserves the neurovascular bundles supplying the rectus complex and dissection in the correct plane prevents the formation of new, challenging unintended hernia defects and provides for wide prosthetic overlap offering the patient a sustainable repair. Lastly, we highlight key postoperative factors that affect a patient's recovery. Avoidance of surgical error traps combined with technique mastery can lead to the successful repair of challenging abdominal wall defects using the TAR approach.

S116: Impact of incisional negative pressure wound therapy on surgical site infection after complex incisional hernia repair: a retrospective matched cohort study.

Incisional negative pressure wound therapy (iNPWT) may reduce surgical site infections (SSI), which can have devastating consequences after incisional hernia repair. Few comparative studies investigate the effectiveness of this wound management strategy in this population. The objective of this study is to determine the effect of iNPWT on the incidence of SSI after complex incisional hernia repair. All adult patients undergoing open incisional hernia repair at a single center from 2016 to 2019 were reviewed. A commercial iNPWT dressing was used at the discretion of the surgeon. Patients were grouped by type of dressing; iNPWT and standard sterile dressings (SSD). Coarsened exact matching was used to create balanced cohorts for comparison using age, sex, American Society ofAnesthesiologists classification, wound classification, and surgical urgency. The primary outcome was the composite incidence of superficial and deep SSI within 30days. Secondary outcomes included non-infectious surgical site occurrences (SSO), overall complications, length of stay (LOS), emergency department visits, and readmission at 30days. 134 patients underwent complex hernia repair, with 114 patients included after matching (34 iNPWT, 51 SSD). Composite incidence of superficial and deep SSI was 19.3% (11.8% vs. 27.5%, p = 0.107), with significantly lower rates of deep SSI in patients receiving iNPWT (2.9% vs. 17.6%, p = 0.045). After accounting for residual differences between groups, iNPWT was associated with decreased incidence of composite SSI (RR 0.36, 95% CI [0.16, 0.87]). Median LOS was longer in patients with iNPWT (7 vs. 5days, p = 0.001). There were no differences in SSO, overall complications, readmission, or emergency department visits. In patients undergoing incisional hernia repair, the use of iNPWT was associated with a lower incidence of SSI at 30days. Future studies should focus on cost effectiveness of iNPWT, its impact on long-term hernia recurrences, and the identification of patient selection criteria in this population.

Long-term results of botulinum toxin type A in complex abdominal wall repair and review of the literature.

Administration of botulinum toxin (BTX) is being used in cases of complex ventral hernia for the reconstruction of the linea alba and closure of the abdominal wall. However, there are no published results regarding the long-term effects of BTX and its implication in hernia recurrence. Our purpose is to evaluate the outcomes in hernia recurrence of the administration of BTX in complex ventral hernia repair. 36 patients underwent elective surgery for complex ventral hernia and were evaluated retrospectively. The study included patients with a transverse hernia defect ≥ 100mm and loss of domain hernias, receiving BTX injections 6weeks prior to elective surgery. Global results and long-term recurrence were analysed. There were no complications related to BTX administration. The mean transverse hernia defect was 139.44 ± 50.98mm, the mean abdominal cavity volume (ACV) was 10.19 ± 3.33dm3, the mean hernia sac volume (HSV) was 1.93 ± 1.79dm3, presenting a mean volume ratio (VR) of 20.71 ± 19.76%. Primary closure was achieved in 28 patients (77.8%), 21 of whom (75%) needed an anterior component separation technique. Recurrence rate was 11.4% at 2-years follow-up. BTX administration is a safe and feasible method for abdominal wall expansion prior to complex incisional hernia repair, achieving high rates of primary closure. Long-term follow-up shows good results in terms of recurrence in these patients.

Do drain tubes help reduce risks of post-operative complications in complex incisional hernia repair (as defined by a recent court ruling)?

A recent legal case described in the ANZ Journal of Surgery has sparked significant topical interest in drain tube use in incisional hernia repairs in Australia. This study reviews a single centre experience of drain tube use in incisional hernia repair. Data from online clinical records was collected retrospectively from patients that underwent incisional hernia repair from 1 January 2013 to 31 December 2017. 'Complexity' factors of smoking, obesity and lower midline incision (as identified by the legal case) were also used to stratify groups. A total of 410 incisional hernia repair cases were identified during the 5-year period. Median length of stay of the non-drain placement group was significantly shorter than that of the drain placement group (2 versus 6 days, P < 0.001). In total, 10.8% of patients with drain suffered from post-op wound infection compared to 3.6% in patients without a drain tube in-situ (P = 0.005). Seroma rates were no different with or without a drain (15.7% versus 16.9% P = 0.78). When stratified by 'complexity', there was a trend towards increased complications when drains were used. Drain tubes were placed in only a small proportion of patients during incisional hernia repairs and were associated with a higher post-operative wound infection rate. When stratified by the 'complexity' factors outlined by the recent legal case, complications in more 'complex' patients may actually increase when a drain tube is used.

Comparing outcomes of the endoscopic and open external oblique myofascial release

AIMS: The external oblique release (EOR) is a well-described technique for myofascial advancement during hernia repair. One of the reported drawbacks of an open approach is the high wound morbidity associated with this procedure. One proposed technique to reduce wound morbidity is the endoscopic EOR. The purpose of this study was to compare the outcomes of the open and endoscopic EOR. METHODS: Data from the Americas Hernia Society Quality Collaborative were queried on May 10, 2017. All patients undergoing open or endoscopic incisional hernia repair with an EOR were evaluated with comparative outcomes including hernia recurrence, quality of life, and 30-day wound complications. RESULTS: Four hundred and eighty-five patients met inclusion criteria of undergoing open or endoscopic EOR. Surgical site infections (SSIs) occurred in 6% of the patients undergoing open EOR and 14% undergoing endoscopic EOR. There were no differences in outcomes comparing open and endoscopic EOR for hernia recurrence, quality of life, or 30-day SSI rate (P > 0.05). Laparoscopic EOR had a significantly higher rate of surgical site occurrences (SSOs) compared with open EOR (P 0.05). CONCLUSIONS: Equivalent outcomes were achieved using the open or endoscopic EOR technique in open repair of incisional hernia. Both techniques offer good outcomes and are important adjuncts in the repair of complex incisional hernias.

Outcomes using indocyanine green angiography with perforator-sparing component separation technique for abdominal wall reconstruction.

Usage of intraoperative indocyanine green (ICG) to assess skin flaps prior to abdominal wall closure has been shown to decrease postoperative wound-related complications. Primary outcome assessed is the utility of ICG in intraoperative decision making. Secondary outcomes analyzed are the incidence of surgical site occurrence (SSO) and hernia recurrence rates. A retrospective study using the MedStar Georgetown University Hospital database was conducted, incorporating all consecutive patients undergoing complex incisional hernia repair from 2008 to 2018. 146 patients underwent perforator-sparing component separation (PSCST), 88 underwent flap assessment using intraoperative ICG angiography; they were then analyzed based on patient comorbidities, Ventral Hernia Working Group grade, operative factors, and complications. A total of 146 patients were analyzed with no statistical difference in patient characteristics between the SPY and no SPY group except in BMI (30.2 vs. 33.2kg/m2, p = 0.036). The no SPY group also had higher numbers of patients undergoing concurrent panniculectomy (12 vs. 1, p < 0.001), and extensive lysis of adhesions (30 vs. 31, p = 0.048). Of the 88 patients undergoing intraoperative SPY, 37 (42%) patients had a change of intraoperative management as defined by further subcutaneous skin flap debridement. Despite this change, there was no statistical difference in incidence of SSO between SPY and no SPY (24.3% vs. 11.8%, p = 0.12), and no difference in hernia recurrence rates 5.6% (n = 5) versus 13.7% (n = 8), p = 0.09. Intraoperative ICG assessment of subcutaneous skin flaps with a perforator-sparing component separation does not result in a decrease in surgical site occurrences.

Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation.

Incisional hernias (IH) after orthotopic liver transplant (OLT) are challenging due to their concurrent midline and subcostal defects adjacent to bony prominences in the context of lifelong immunosuppression. To date, no studies evaluated the posterior component separation with transversus abdominis release (TAR) to repair complex IH after OLT. We aim to report the outcomes of TAR in this scenario. OLT patients who underwent open, elective IH repair with TAR performed at two centers and with a minimum of 1-year follow-up were identified in the Americas Hernia Society Quality Collaborative (AHSQC). Outcomes included 30-day surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), unplanned readmissions, reoperations, and hernia recurrence. Forty-four patients were identified (mean age 60 ± 8, 75% male, median BMI 30.7kg/m2) at two centers. Median hernia width was 20cm [IQR 15-28] and 98% (43) were clean cases. Retromuscular synthetic mesh was used in all cases, and 93% (41) achieved fascial closure with no intraoperative complications. Postoperatively, there were 5 SSIs (4 deep, 1 superficial), 6 SSOPIs (4 wound opening, 1 debridement, 1 seroma drainage), four (9%) readmissions, and 3 (7%) reoperations. One patient developed a mesh infection that did not require mesh excision. After a median follow-up of 13 months [IQR 12-17], there were 11 (25%) recurrences; 8 due to central mesh fractures (CMF). Seven recurrences have been repaired either laparoscopically or using an onlay. In a challenging cohort of immunosuppressed patients with large IH, TAR was shown to have acceptable medium-term results, but high recurrence rate driven by CMF. Further studies investigating the mechanism of central mesh fractures are necessary to reduce these recurrences.