Repair Of Large Ventral Hernias Research Articles

The outcomes of component separation technique versus no component separation technique in the repair of large ventral hernias and impact on quality of life: a multicenter retrospective cohort study.

This study aimed to compare the results of patients who underwent anterior component separation techniques (ACST) and those who did not undergo component separation techniques (non-CST) in complicated ventral hernia repairs (VHRs) and to investigate the effect of these techniques on quality of life (QoL). A total of 105 patients who were operated for large ventral hernias were retrospectively analyzed. The patients were divided into the ACST group (n = 48) and the non-CST group (n = 57). Demographic, intraoperative, and postoperative data were recorded. Postoperative follow-up was conducted at 2 and 4 weeks, and 6, 12, and 24 months. The primary and secondary outcomes and QoL were measured. The female ratio was higher in both groups (P = 0.512). There was no significant difference between age and body mass index between the groups (P = 0.705 and P = 0.803). The mean defect size and mesh size were similar between the groups (P = 0.775 and P = 0.245). The mean operation duration and amount of blood loss were similar between the groups (P = 0.801 and P = 0.142). There was no statistically significant difference in the median visual analog scale scores between the groups (P = 0.551). During follow-up, only 3 patients (6.3%) in the ACST group and 4 patients (7.0%) in the non-CST group had recurrence. There was no significant difference in the short- and long-term QoL between the groups. The ACST is a feasible surgical option for patients with complicated VHRs. In addition, by improving QoL, the recurrence rate is similar to patients undergoing standard VHR.

Posterior components separation with transversus abdominis release and sublay mesh reinforcement in large ventral hernia repair

AbstractAimVentral abdominal hernia is a prevalent condition among surgical patients. Large ventral hernias with defects >10 cm that cannot be closed primarily, often with loss of domain requiring abdominal wall reconstruction, pose a surgical challenge. Our study aimed to evaluate the outcomes of posterior components separation (PCS) with transversus abdominis release (TAR) and sublay mesh reinforcement in large ventral hernia repair, particularly in terms of surgical site occurrences (SSOs) and hernia recurrence.Patients and MethodsOur study included 40 adult patients presented to Tanta University Hospitals with a large ventral hernia (defect width ≥10 cm) from December 2021 to January 2023. All patients were submitted to PCS with TAR and sublay mesh reinforcement.ResultsThe mean age of the study population was 47.32 (standard deviation [SD] 9.31) years (range 36–65 years) with a mean body mass index of 33.55 (SD 3.42) kg/m2 (range 28.35–38.72 kg/m2). The major risk factors were obesity (95.00%), smoking (45.00%), and multiparity (45.00%). Midline incisional hernia was the most common type in 28 patients (70.00%). Thirty‐four patients (85%) achieved successful midline closure, while six patients required additional anterior components separation technique to achieve tensionless midline closure and an onlay mesh for functional reconstruction. Post‐operative SSOs occurred in 12 patients (30.00%), with subcutaneous seroma in 8 patients (20.00%) and wound dehiscence and necrosis in 4 patients (10.00%). Two patients (5.00%) experienced recurrence after a mean follow‐up period of 19.25 (SD 3.52) months.ConclusionsPCS with TAR and sublay mesh reinforcement is a reliable and durable technique for complex ventral hernia repair with low morbidity and recurrence rates. However, long‐term clinical outcomes with more cases are required to properly evaluate this technique.

Hospital costs of robotic-assisted and open treatment of large ventral hernias

Robotic-assisted treatment of ventral hernia offers many advantages, however, studies reported higher costs for robotic surgery compared to other surgical techniques. We aimed at comparing hospital costs in patients undergoing large ventral hernia repair with either robotic or open surgery. We searched from a prospectively maintained database patients who underwent robotic or open surgery for the treatment of the large ventral hernias from January 2016 to December 2022. The primary endpoint was to assess costs in both groups. For eligible patients, data was extracted and analyzed using a propensity score-matching. Sixty-seven patients were retrieved from our database. Thirty-four underwent robotic-assisted surgery and 33 open surgery. Mean age was 66.4 ± 4.1 years, 50% of patients were male. After a propensity score-matching, a similar total cost of EUR 18,297 ± 8,435 vs. 18,024 ± 7514 (p = 0.913) in robotic-assisted and open surgery groups was noted. Direct and indirect costs were similar in both groups. Robotic surgery showed higher operatory theatre-related costs (EUR 7532 ± 2,091 vs. 3351 ± 1872, p < 0.001), which were compensated by shorter hospital stay-related costs (EUR 4265 ± 4366 vs. 7373 ± 4698, p = 0.032). In the treatment of large ventral hernia, robotic surgery had higher operatory theatre-related costs, however, they were fully compensated by shorter hospital stays and resulting in similar total costs.

Robotic-Assisted Treatment of Large Incisional Abdominal Wall Hernias: A Cost Analysis

Abstract Background Robotic-assisted treatment of ventral hernia offers many advantages, however, studies reported higher costs for robotic surgery compared to other surgical techniques. Aims We aimed at comparing hospital costs in patients undergoing large ventral hernia repair with either robotic or open surgery. Methods We retrospectively searched from a prospectively maintained database patients who underwent robotic or open surgery for the treatment of the large ventral hernias from January 2016 to December 2022. The primary endpoint was to assess the costs incurred by the hospital in both groups. For eligible patients, data was extracted analyzed using a propensity score-matching. Results During the study period, 67 patients were retrieved from our database. 34 patients underwent robotic-assisted surgery while 33 underwent open surgery. Mean age was 66.4 years ±4.1 years, 50% of patients were male. After a propensity score-matching, a similar total cost of 18,297±8,435 EUR vs. 18,024±7,514, p=0.913 in robotic-assisted and open surgery groups were noted. Robotic surgery showed higher operatory theatre-related costs (7,532±2,091 EUR vs. 3,351±1,872 EUR, p&amp;lt;0.001), which were fully compensated by a shorter hospital stay of 5.3±4.5 vs. 10.4±5.2 days, p=0.002 (costs: 4,265±4,366 EUR vs. 7,373±4,698 EUR, p=0.032). Conclusion Our study showed that in the treatment of large ventral hernia, robotic surgery had higher operatory theatre-related costs, however, they were fully compensated by shorter hospital stays and resulting in similar total costs.

Descriptive Analysis of Outcomes After Onlay Ventral Hernia Repair in Obese Patients.

To determine outcomes after on lay large ventral hernia repair in obese patients. Large ventral hernia repairs (VHR) in obese patients remain a challenge. Obesity is a risk factor for intraoperative difficulties and postoperative complications. Recurrence rates after VHR in obese patients range between 12-50% versus 10% in nonobese patients. While results of laparoscopic techniques in VHR compare favorably to open, outcomes in correlation with obesity, technique, and defect size are less understood. A single surgeon's experience of 329 consecutive VHR between 2013-2022 was retrospectively reviewed. Inclusion criteria were obesity (BMI >30) and large hernia defects (>5cm). A modified onlay technique was used which included component release and a lightweight monofilament polypropylene mesh. Primary outcome measures were hernia recurrence and wound complications. A total of 56 patients met inclusion criteria. Patients were majority male (n=30, 54%), with a median age of 58.5years (inter quartile range (IQR) 33-83), and median BMI of 36kg/m2 (IQR: 30-72). Median hernia defect size was 8cm (IQR: 5-15). Twenty patients had undergone prior mesh repairs. Median follow-up was 52 months (IQR: 6months-9years). Two patients experienced recurrence (3.6%) and four experienced wound complications (four seromas, one panniculitis, 8.9%). No patients suffered flap ischemia or necrosis. Obesity is a risk factor for poor outcomes after VHR. We developed a protocol for obese patients with large defects involving a modified onlay technique which demonstrates comparable results to other VHR techniques in obese patients.

Technical aspects of performing laparoscopic hernioplasty in the treatment of large ventral hernias

Laparoscopic hernioplasty is a promising treatment option for ventral hernias. The technique of intraperitoneal mesh placement (IPOM) is the most extensively studied and widely used for the closure of a defect during laparoscopic hernia repair. The large size of the defect and its diameter exceeding 10 cm are limiting factors in the selection of minimally invasive techniques for hernioplasty. The process of suturing the hernia prior to the placement of the mesh, as well as the technique used to fix it, show controversial results in terms of postoperative quality of life and the risk of recurrence. Objective — to study the technical aspects of performing laparoscopic prosthetic hernioplasty using the IРOM technique for the surgical treatment of patients with large primary ventral hernias (PVH) and postoperative incisional ventral hernias (IVH). Materials and methods. The study included a total of 84 patients who were undergoing treatment at the clinical base of the Department of General Surgery No. 2 of Bogomolets National Medical University. There were 51 (60.7%) women and 33 (39.3%) men. The average age was 58.73±10.9 years. All patients were operated on for large ventral hernias. Of these, 52 (61.9%) patients had surgery for PVH (umbilical hernia, line alba hernia), while 32 (38.1%) — for IVH. In 56 (66.7) patients, the width of the hernia defect was &gt; 10 cm, of which 24 (28.6%) patients had PVH. In these patients, 4 weeks before surgery, 100 units of botulinum toxin type A (BTA) were injected intramuscularly into the muscles of the anterior abdominal wall in accordance with the methodology developed in the clinic. All patients underwent laparoscopic prosthetic hernioplasty with IPOM under general combined anesthesia. Control examinations of patients were carried out 2 weeks, 1 month, 6 months, and 1 year after the operation. Results. All patients underwent IPOM, while 38 (45.2%) patients underwent laparoscopic IPOM with suturing of the defect, 36 (42.9%) patients underwent IPOM with suturing the hernia defect before placing the mesh (IPOM+), and 10 (11.9%) patients underwent IPOM without suturing the defect. 32 (38.1%) patients were aged 65 years, including 10 patients who did not undergo suturing of the defect before the mesh placement. After the injection of BTA, the number of patients with a defect width of ≥10 cm decreased to 15 (17.8%). All of these patients had a defect smaller than 15 cm. The average duration of surgery for IPOM without hernia suturing was 60.00±11.30 min; for IPOM with laparoscopic suturing, it was 108.16±40.29 min; for IPOM+ with open suturing, it was152.08±40.64 min. The average length of stay in the hospital after surgery was higher in the group of patients who underwent hernioplasty using the IPOM+ technique compared to other techniques (p &lt;0.001). In the early postoperative period, the complication rate was 13.1%; all cases were classified as minor (Grade I, II, IIIa) according to the Clavien–Dindo classification. Conclusions. Laparoscopic hernioplasty using the IPOM is a safe and reliable method for large ventral hernia repair. Administering preoperative BTA injections enables the reduction of the defect and facilitates the execution of laparoscopic hernioplasty in patients with a primary hernia size of ≥10 cm.

Transversus abdominis release with biosynthetic mesh for large ventral hernia repair: a 5-year analysis of clinical outcomes and quality of life.

Transversus abdominis release (TAR) may provide an optimal plane for mesh placement for large ventral hernias requiring medial myofascial flap advancement. Long-term outcomes of TAR for large ventral hernia repair (VHR) remains under-studied. This study aims to assess longitudinal clinical outcomes and quality of life (QoL) following large VHR with TAR and resorbable biosynthetic mesh. Retrospective review of clinical outcomes and prospective QoL was performed for patients undergoing VHR with poly-4-hydroxybutyrate mesh and TAR from 2016 to 2021. Patients with ≤ 24months of follow-up, defects ≤ 150cm2, and parastomal hernias were excluded. Cost-related data was collected for each patient's hospital course. QoL was compared using paired Wilcoxon signed-rank tests. Twenty-nine patients met inclusion criteria. Median age and BMI were 61years (53.2-68.1years) and 31.4kg/m2 (26.1-35.3kg/m2). Average hernia defect was 390cm2 ± 152.9cm2. All patients underwent previous abdominal surgery and were primarily Ventral Hernia Working Group 2 (58.6%). Two hernia recurrences (6.9%) occurred over the median follow-up period of 63.1months (IQR 43.7-71.3months), with no cases of mesh infection or explantation. Delayed healing and seroma occurred in 27 and 10.3% of patients, respectively. QoL analysis identified a significant improvement in postoperative QoL (p < 0.005), that continued throughout the 5-year follow-up period, with a 41% overall improvement. Cost analysis identified the hospital revenue generated was approximately equal to the direct costs of patient care. Higher costs were associated with ASA class and length of stay (p < 0.05). Large VHR with resorbable biosynthetic mesh and TAR can be performed safely, with a low recurrence and complication rate, acceptable hospital costs, and significant improvement in disease-specific QoL at long-term follow-up.

OC-010 5-YEAR ASSESSMENT OF RESORBABLE BIOSYNTHETIC MESH WITH TRANSVERSE ABDOMINIS RELEASE FOR LARGE VENTRAL HERNIA REPAIR: A LONG-TERM EVALUATION OF CLINICAL OUTCOMES AND QUALITY OF LIFE

Abstract Aim This study assesses long-term clinical and quality-of-life (QoL) outcomes following large ventral hernia repair (VHR) with transverse abdominis release (TAR) using resorbable biosynthetic mesh. Methods Retrospective review of clinical outcomes with prospective assessment of QoL was performed for patients undergoing VHR with Poly-4-hydroxybutyrate[P4HB]/Phasix mesh (C.R. Bard, Warwick, RI) and TAR from 2016–2021. Patients with less than 24 months of follow-up, defects smaller than 150cm2, and parastomal hernias were excluded. Results Sixty-nine patients were initially identified. Twenty-nine patients met inclusion criteria. Median age and BMI were 61 years (IQR 53.2–68.1 years) and 31.4 kg/m2(IQR 26.1–35.3kg/m2). Average hernia defect was 390cm2±152.4cm2. All patients underwent previous abdominal surgery and were primarily VHWG 2 (55.2%). Two hernia recurrences (6.9%) occurred over the median follow-up period of 63.1 months (IQR 43.7–71.3 months). Delayed healing and seroma occurred in 27% and 10.3% of patients, respectively. There were no cases of mesh infection or explantation. Cost analysis revealed no significant average margin loss(p&amp;gt;0.05) and risk-adjusted analysis demonstrated higher costs associated with ASA class and length of stay(p&amp;lt;0.05). Throughout the study period, patients demonstrated a significant improvement in long-term postoperative QoL(p&amp;lt;0.005). This was seen continuously throughout the 5-year follow up period (p&amp;gt;0.05), with an 80% response rate and overall average improvement of 41% compared to preoperative QoL. Conclusion Large VHR with resorbable biosynthetic mesh and TAR can be performed safely and effectively leading to an optimal ratio of recurrence and mesh infection at acceptable costs and with significant and sustained improvement in disease-specific QoL at long-term follow-up.

Effects of Novel Multimodal Transversus Abdominis Plane Block on Postoperative Opioid Usage and Hospital Length of Stay Following Elective Ventral Hernia Repair.

Background and objective Traditional transversus abdominis plane (TAP) blocks consisting of a local anesthetic, typically bupivacaine, have previously been shown to reduce postoperative pain following gastrointestinal surgery, including hernia repair. However, elective abdominal wall reconstructions for the repair of large ventral hernias continue to cause patients significant postoperative pain, resulting in prolonged hospital stays and need for opioid pain medication. This study aimed to analyze the postoperative opioid pain medication usage and hospital length of stay (LOS) in patients who received a nontraditional multimodal TAP block of ropivacaine (local anesthetic), ketorolac (non-steroidal anti-inflammatory), and epinephrine following elective ventral hernia repair. Methods A retrospective review of medical records for patients who underwent elective robotic ventral hernia repair by a single surgeon was conducted. Postoperative hospital LOS and opioid usage for patients with the multimodal TAP block were compared to those without. Results A total of 334 patients met the inclusion criteria for LOS analysis: 235 received the TAP block and 109 did not. Patients who received the TAP block had a statistically significant shorter LOS compared to patients who had no TAP block (1.09 ± 1.22 days vs. 2.53 ± 1.57 days; P<0.001). Medical records for 281 patients, 214 with the TAP block and 67 without the TAP block, contained information and were analyzed for postoperative opioid usage. A statistically significantly fewer number of patients who had the TAP block required hydromorphone patient-controlled analgesia pump (3.3% vs. 36%; P<0.001) and oral opioids (29% vs. 78%; P<0.001) postoperatively. Those with TAP block required intravenous opioids more frequently (50% vs 10%; P<0.001) although at much less dosages than those without TAP block (4.86 ± 2.62 mg vs. 10.29 ±3.90 mg; P<0.001). Conclusion In conclusion, this multimodal TAP block of ropivacaine, ketorolac, and epinephrine may represents an effective method to improve hospital LOS and postoperative opioid usage in patients undergoing robotic abdominal wall reconstruction for ventral hernia repair.

Surgical and Patient-Reported Outcomes of Open Perforator-Preserving Anterior Component Separation for Ventral Hernia Repair.

Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair. A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life. Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m2, respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08-0.62), which corresponds to absence or minimal symptoms. The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality.

Intraperitoneal mesh open repair without dissection technique for large ventral hernia repair: an alternative to component separation technique.

Incisional hernias (IH) are one of the major complications following abdominal surgery and the treatment of large abdominal hernias represents a challenge for the surgeon. We present our own modified open intraperitoneal mesh technique, named "IPOW technique" (intra-peritoneal mesh open repair without dissections). We analyzed early postoperative complications (seroma, wound infection, hematoma) and the late ones (recurrence, chronic pain), in 50 unselected patients treated for IH and primary hernia (PH) larger than 5 cm using the proposed laparotomic technique. From January 2019 to September 2021, 50 unselected patients with, at least, one year of follow-up, with hernias ranging from 5 to 25 cm in width, were surgically repaired using IPOW technique. Mean Body Mass Index (BMI) was 29 (range 22-44). In our series, we report 2 (4%) complications and, after a mean follow-up of 847 days (range 481-1357), 2 (4%) recurrences. No patients reported chronic pain. In our experience, we consider IPOW technique easily reproducible, ensuring excellent results with a reduction of invasiveness, comparing to other techniques. Anyway, definitive conclusions require a larger number of patients.

Successful Use of Continuous Erector Spinae Plane Blocks in a Patient With Variant Angina After Large Ventral Hernia Repair

Coronary artery spasm constitutes the primary underlying pathology of variant angina. Because provocation of coronary artery spasm may occur with both excess sympathetic and excess parasympathetic stimulation, patients with this disorder have extremely limited options for perioperative pain control. This is especially true for procedures involving extensive abdominal incision/manipulation. Whereas neuraxial analgesia might otherwise be appropriate in these cases, several studies have demonstrated that coronary artery spasm can occur as a result of epidural placement, and therefore, that this may not be an optimal choice for patients with variant angina. This report discusses the case of a patient with a preexisting diagnosis of variant angina who underwent an exploratory laparotomy with large ventral hernia repair and for whom continuous erector spinae plane blocks were successfully used as analgesic adjuncts without triggering coronary artery spasm.

Bridged repair of large ventral hernia defects using an ovine reinforced biologic: A case series

IntroductionOf all hernia types, large ventral hernias have the most impact on patient quality of life, however they are also the most difficult type of hernia to repair and are associated with high rates of complications. This case series describes repair of large ventral hernias with an ovine reinforced biologic in a complex patient cohort with comorbidities and concomitant procedures. MethodsThe author performed bridged repair with an ovine reinforced biologic in 19 consecutive high-risk patients over a 5-year period. In all cases the reinforced biologic was used as an underlay. OutcomesOf the 19 patients, six (32%) experienced a surgical site occurrence including infection, seroma, abscess, fistula, bioloma, or bowel obstruction. Three patients (16%) had recurrences with two out of three of the recurrences occurring within 6 months of surgery. ConclusionsRates of SSO's and recurrences using ovine reinforced tissue matrix (RTM) were in line with or better than other published studies of bridged repair utilizing biologic or synthetic mesh reinforcement. Ovine RTM's should therefore be considered in complex large ventral hernia repairs.

Management of a Voluminous Incisional Hernia – Case Report and Brief Review

Abstract Introduction: Massive ventral hernia repairs may lead to abdominal compartment syndrome, which is associated with increased morbidity and mortality, and is caused by an acute rise in intra-abdominal pressure, frequently leading to multi-organ failure and possibly death. This report presents a case with a voluminous incisional hernia associated with intestine obstruction and the issues surrounding emergency surgical treatment. Case report: An overweight 67-year-old patient with a medical history of diabetes and multiple cardiovascular pathologies presented to the emergency department complaining of abdominal distension, pain, nausea, vomiting, and lack of intestinal transit for 48 hours. A clinical diagnosis of bowel obstruction was established, caused by a large ventral hernia. During surgery, a tension free abdominal wall reconstruction was performed with a peritoneal flap from the hernia sac and retromuscular Prolene synthetic mesh. A Redon-type drainage of the posterior rectus compartment and subcutis was applied for 48 hours. After the operation, the patient was transferred to the intensive care unit for monitoring. During the follow-up, continuous monitoring of arterial blood pressure, oxygen saturation, renal function, daily diuresis, lactic acid values, and intraabdominal pressure was performed. On the 9th postoperative day, the patient was released in good general health, stable from a cardiorespiratory point of view, with a clean, healing surgical wound. Conclusion: The repair of large ventral hernias is technically challenging. The management of giant incisional hernias is complex, requiring thoughtful preoperative evaluation with CT imaging and volumetry calculation, which can help establish the surgical strategy.

A retrospective comparison of outcomes after open anterior and posterior component separation by a single surgical team.

While both anterior and posterior component separation techniques aid the repair of large ventral hernias, their outcomes can be remarkably dissimilar in terms of wound morbidity. We describe outcomes after open component separation by a single surgical team over the entire breadth of our experience. We queried a prospectively maintained database for ventral hernias who received an open bilateral component separation between January 2014 and January 2020. A retrospective review was performed to analyze patient demographics, perioperative events, adverse outcomes, and recurrence. One hundred twenty-seven patients met the inclusion criteria of which 44 underwent anterior component separation (ACS) and 83 underwent posterior component separation (PCS). The two groups were broadly similar in terms of demographic and hernia-related variables. Mesh:defect area ratios, operative time, and estimated intraoperative blood loss were higher in the PCS group. The ACS group had more frequent use of drains which remained in situ for longer, along with a longer hospital stay. Surgical site occurrences (SSOs), including those needing procedural intervention (SSOPIs) were significantly more common after ACS. This group was also more likely to undergo a reoperation within 30days of index repair. A single recurrence was noted in the ACS group after a mean follow-up duration of 43months. Open PCS may be more technically demanding than ACS, but it has a lower risk of postoperative morbidity and reoperation. While we now utilize PCS more frequently in our practice, ACS remains an important tool in our armamentarium.

Evaluation of outcomes of 5cm all-around mesh reinforcement after endoscopic component separation and midline closure during laparoscopic ventral hernia repair

Background: To evaluate the short term recurrence, pain scores, infection rates and cost factors by using 5cm all around composite mesh reinforcement of the closed defect after endoscopic video-assisted component separation for large ventral hernia repair. Methods: All patients who were clinically assessed to have large (≥5cm diameter of defect) midline ventral hernia underwent an abdominal CT as per protocol to calculate the Component Separation Index and were subjected to endoscopic video-assisted component separation. Next laparoscopy is done, hernial contents were reduced with adhesiolysis and midline defect is closed vertically with VLoc sutures, under physiologic tension. The closed suture line is reinforced with a mesh having a 5cm all round overlap irrespective of the original hernia defect. Results: A total of 30 patients were operated. Over a follow up period ranging from 3-18 months there were no recurrences, no surgical site infection, no seroma formation, no mesh infection, fewer tackers were required resulting in more favorable pain scores. Due to smaller mesh and fewer tackers there was significant cost reduction per case. Conclusion: Endoscopic component separation technique is useful in tension less large midline ventral hernia repair. Only 5cm all around mesh reinforcement of midline closure is required thus significantly cutting down the cost of surgery with excellent patient outcome.

Implementing preoperative Botulinum toxin A and progressive pneumoperitoneum through the use of an algorithm in giant ventral hernia repair.

Repair of large ventral hernias with loss of domain can be facilitated by preoperative Botulinum toxin A (BTA) injections and preoperative progressive pneumoperitoneum (PPP). The aim of this study is to evaluate the outcomes of ventral hernioplasty using a standardized algorithm, including component separation techniques, preoperative BTA and PPP. All patients between June 2014 and August 2018 with giant hernias (either primary or incisional) of more than 12cm width were treated according to a previously developed standardized algorithm. Retrospective data analysis from a prospectively collected dataset was performed. The primary outcome was closure of the anterior fascia. Secondary outcomes included complications related to the preoperative treatment, postoperative complications, and recurrences. Twenty-three patients were included. Median age was 65years (range 28-77) and median BMI was 31.4 (range 22.7-38.0kg/m2). The median loss of domain was 29% (range 12-226%). For the primary and secondary endpoints, 22 patients were analyzed. Primary closure of the anterior fascia was possible in 82% of all patients. After a median follow-up of 19.5months (range 10-60months), 3 patients (14%) developed a hernia recurrence and 16 patients (73%) developed 23 surgical site occurrences, most of which were surgical site infections (54.5%). Our algorithm using both anterior or posterior component separation, together withpreoperative BTA injections and PPP, achieved an acceptable fascial closure rate. Further studies are needed to explore the individual potential of BTA injections and PPP, and to research whether these methods can prevent the need for component separation, as postoperative wound morbidity remains high in our study.

Abdominal Wall Reconstruction (AWR): Initial Experience from an Indian Centre

Posterior component separation through transverse abdominis muscle release (TAR) is a relatively new surgical technique and gaining popularity for complex large ventral hernia repair. This is a single centre, retrospective study involving ventral hernia cases managed by abdominal wall reconstruction during 2017–18. Patient demographics, body mass index (BMI), comorbidities, type of surgery, mesh size, complications, pain score, length of stay, and recurrence were recorded from the medical records and analysed statistically as mean, standard deviation, median, range, and percentile as applicable. The study included 14 cases presenting with incisional ventral hernia. Mean BMI of the study population was 28 ± 5.26 kg/m2 and mean age was 60.28 ± 9.68 years. Three different types of mesh were used for reinforcing the abdominal layers separated during the surgery. The average hospital stay was 4.71 ± 1.43 days and median follow-up was 12 months. There were no major complications reported post surgery; however, surgical site infection was reported in 4 (28.57%) patients. One patient (male, 60 years, BMI 34.5 kg/m2, M2, M3 hernia and defect size of 18 × 20 cm), reported a minor bulge after 2 years of surgery. Transverse abdominis muscle release surgical technique is giving satisfactory results and can be safely adopted as an alternate to existing techniques for treating large, incisional midline ventral hernia in Indian population.

Preoperative, single, high-dose glucocorticoid administration in abdominal wall reconstruction: A randomized, double-blinded clinical trial

BackgroundAlthough preoperative administration of high-dose glucocorticoid may lead to improved recovery after operative procedures, this regimen has not been examined in patients undergoing abdominal wall reconstruction for repair of large ventral hernias. The aim of the current trial was to examine the effects of preoperative, single high-dose glucocorticoid on recovery after abdominal wall reconstruction. MethodForty patients undergoing abdominal wall reconstruction for repair of ventral incisional hernias with a horizontal fascial defect >10 cm were randomized to intravenous administration of either 125 mg methylprednisolone or placebo at the induction of anesthesia. The primary endpoint was pain in the supine position as assessed by a numeric rating scale of 0 to 10 at rest at 8 am on the first postoperative day. Secondary outcomes included postoperative pain during activity, nausea, fatigue, inflammatory response (measured by plasma levels of C-reactive protein), duration of stay, and 30-day complications or readmissions. ResultsThere was no difference in pain at rest on the first postoperative day (methylprednisolone mean 1.7 vs placebo 2.2, P > .95), whereas patients in the methylprednisolone group reported less pain during activity (mean 3.0 vs 5.0; P = .011) and during coughing (3.4 vs 5.9; P = .010). There were no differences between the 2 groups regarding postoperative fatigue or nausea. Postoperative levels of C-reactive protein were less in the methylprednisolone group (P = .039). ConclusionA single-shot, high-dose methylprednisolone before abdominal wall reconstruction for a large incisional hernia decreased early postoperative pain and attenuated the inflammatory response.

Quality of Life after Complex Abdominal Wall Reconstruction

Background: Component separation (CS) for tension-free approximation of fascial edges is the established technique for the repair of large ventral hernias mostly regarding midline defects. Recent studies suggest lower complication rates following a modified version of this technique using a partially endoscopic-assisted approach, whereas little is known about the quality of life (QoL) in the long-term evaluation of these patients. Methods: A retrospective study and analysis of patients undergoing hernia repair using an open CS (OCS) and endoscopically assisted CS (ECS) technique, respectively, from 2011 to 2016 at the Rostock University Medical Center. Patients underwent a mesh-based sublay reinforcement following a distinct CS with closure of the linea alba. Patient characteristics, technical details, and short-term postoperative outcomes were determined by a physician chart review. A health-related QoL survey (EQ-5D) including a pain assessment was evaluated at a median of 19.5 months postoperatively. Results: Thirty-five patients had a CS: 25 OCS and 10 ECS. Perioperative variables were comparable except for the median defect size (169 cm² OCS vs. 86 cm² ECS; p < 0.05) and maximum width of hernia (25 vs. 13 cm). Hospitalization lasted 16.6 days in the OCS group and 7.9 days in the endoscopic group (p = 0.04). Wound complications occurred in 24% of OCS and 10% of ECS patients. Conclusions: Patients in the ECS group had a shorter hospital stay and less minor and major wound complications. These advantages led to a faster recovery directly affecting the QoL in the ECS group. This effect diminishes in the long-term follow-up with a positive trend towards the OCS technique.