Recurrent Incisional Hernia Repair Research Articles

Outcomes of recurrent incisional hernia repair by open and laparoscopic approaches: a propensity score-matched comparison.

Recurrent incisional hernias are challenging, and their surgical outcomes have not been well studied. We aimed to analyze the outcomes of recurrent incisional hernia repair in a propensity score-matched cohort study on laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) versus open sublay repair. All consecutive patients who had undergone open sublay repair and lap. IPOM of recurrent incisional hernia between January 2015 and December 2021 at a tertiary hernia center was identified. One-to-one propensity score matching was used to achieve a balanced exposure groups at baseline. Of 255 patients, 85/95 with open sublay repair were matched to 85/160 with lap. IPOM. Before matching, the open sublay group had significantly larger hernia defects (6.3cm vs. 5.0cm) than the lap. IPOM group. Other major baseline imbalances were also found in body mass index (BMI), obesity and European Hernia Society (EHS) width classification. The pre-match results showed that the lap. IPOM group had significantly shorter operative time (median 75 vs. 95min) and shorter postoperative hospital stay (median 8 vs. 11days) compared with the open sublay group. Wound infection (8.4% vs. 1.9%) and hematoma (5.3% vs. 0.6%) occurred more frequently after open sublay repair. After matching, baseline characteristics were well balanced. The recurrence rate and incidence of complications were comparable between the two groups. However, the post-match analysis still showed that lap. IPOM was associated with decreased length of postoperative stay. The outcomes of recurrent incisional hernia surgery after lap. IPOM and open sublay repair appear similar, except that the former had shorter length of postoperative stay. However, the poor outcomes were more likely associated with the unfavorable risk profiles, such as larger defect size, rather than the procedure technique itself.

Association of Nicotine Cessation Time on the Incidence of Recurrent Incisional Hernia Repair and Postoperative Surgical Site Occurrences.

Nicotine products are believed to be associated with a higher incidence of incisional hernia (IH) recurrence and postoperative complications after IH repair. A retrospective analysis of the Abdominal Core Health Quality Collaborative (ACHQC) database was performed. Outcomes included risk of IH recurrence, 30-day surgical site infection (SSI), and 30-day surgical site occurrence (SSO). We included 14,663 patients. Nicotine users who quit within 1year of surgery had a 26% higher risk of IH recurrence compared to patients who quit more than a year before surgery or never users. Patients who quit using nicotine within 1year of surgery had a 54% higher odds of SSI compared to former nicotine users who quit more than a year before surgery. Former nicotine users with less than 1year of nicotine use cessation before surgery exhibited worse outcomes than those with more than a year of cessation or no prior use.

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.

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.

A retrospective review and observations over a 16-year clinical experience on the surgical treatment of chronic mesh infection. What about replacing a synthetic mesh on the infected surgical field?

To review the short- and long-term results in patients who underwent removal of infected or exposed mesh and reconstruction of the abdominal wall with simultaneous mesh replacement. Patients undergoing removal of an infected or exposed mesh and single-staged reconstruction of the abdominal wall with synthetic mesh replacement over a 16-year period were retrospectively reviewed from a prospectively maintained database. Patients were operated and followed by a single surgeon. Outcome measures included wound complications and hernia recurrence. From 1996 until 2012, 41 patients (23 F, 18 M), with a mean age of 53.4 years and mean BMI of 31.2 ± 8 kg/m(2), were treated for chronic mesh infection (CMI). A suppurative infection was present in 27 patients, and 14 had an exposed mesh. The need for recurrent incisional hernia repair was observed in 25 patients; bowel resections or other potentially contaminated procedures were associated in 15 patients. The short-term results showed an uneventful post-operative course after mesh replacement in 27 patients; 6 (14.6%) patients developed a minor wound infection and were treated with dressings and antibiotics; 5 (12%) patients had wound infections requiring debridement and one required complete mesh removal. On the long-term follow-up, there were three hernia recurrences, one of which demanded a reoperation for enterocutaneous fistula; 95% of the patients submitted to mesh replacement were considered cured of CMI after a mean follow-up of 74 months. CMI can be treated by removal of infected mesh; simultaneous mesh replacement prevents hernia recurrence and has an acceptable incidence of post-operative acute infection. Standard polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.

Incisional hernia recurrence through genomic profiling: a pilot study

PurposeAlthough situational risk factors for incisional hernia formation are known, the methods used to determine who would be most susceptible to develop one are unreliable. We hypothesized that patients with recurrent incisional hernias may possess unique gene expression profiles.MethodsSkin and intact fascia were collected from 15 normal control (NC) patients with no hernia history and 18 patients presenting for recurrent incisional hernia (RH) repair. Microarray analysis was performed using whole genome microarray chips on NC (n = 8) and RH (n = 9). These samples were further investigated using a pathway-specific PCR array containing fibrosis-related genes.ResultsMicroarray data revealed distinct differences in the gene expression profiles between RH and NC patients. One hundred and sixty-seven genes in the skin and 7 genes in the fascia were differentially expressed, including 8 directly involved in collagen synthesis. In particular, GREMLIN1, or bone morphogenetic protein antagonist 1, was under expressed in skin (fold = 0.49, p < 10−7, q = 0.0009) and fascia (fold = 0.23, p < 10−4, q = 0.095) of RH patients compared with NC. The PCR array data supported previous reports of decreased collagen I/III ratios in skin of RH versus NC (mean = 1.51 ± 0.73 vs. mean = 2.26 ± 0.99; one-sided t test, p = 0.058).ConclusionTo our knowledge, this is the first microarray-based analysis to show distinct gene expression profiles between the skin and fascia of RH and NC patients and the first report of an association between GREMLIN1 and incisional hernia formation. Our results suggest that gene expression profiles may act as surrogate markers that stratify patients into different groups at risk for hernia development prior to their initial surgery.Electronic supplementary materialThe online version of this article (doi:10.1007/s10029-012-0923-4) contains supplementary material, which is available to authorized users.

Laparoscopic Sleeve Gastrectomy: a First Step for Rapid Weight Loss in Morbidly Obese Patients Requiring a Second Non-Bariatric Procedure

Laparoscopic sleeve gastrectomy is a viable option that is becoming common in the management of morbid obesity. The aim of this study was to examine the effectiveness and safety of laparoscopic sleeve gastrectomy as a primary step for rapid weight loss in patients who required a second non-bariatric procedure. After Internal Review Board approval and with adherence to HIPAA guidelines, we conducted a retrospective review of a prospectively collected database of all patients who underwent laparoscopic sleeve gastrectomy as a primary procedure for a second non-bariatric operation from November 2004 to September 2008 at the Bariatric and Metabolic Institute at Cleveland Clinic Florida. The data was reviewed for age, gender, percentage of excess weight loss (%EWL), preoperative and postoperative body mass index (BMI), morbidity, and mortality. Mean follow-up time was 7 months (range, 2 weeks-12 months). Laparoscopic sleeve gastrectomy was performed in 18 patients who needed a second non-bariatric procedure such as knee replacement surgery, recurrent incisional hernia repair, laminectomy of the lumbar spine, kidney transplant, anterior cervical discectomy, and nephrectomy. Mean preoperative weight and BMI were 124.9 kg (range, 95.5-172.3 kg) and 44.87 kg/m2 (range, 33.36-58.87 kg/m2), respectively. Mean postoperative weight and BMI were 99.2 kg (range, 68.2-132.2 kg) and 35.79 kg/m2 (range, 23.46-48.97 kg/m2), respectively. There were no conversions to an open procedure in this series. There was no morbidity or mortality in this series. In this small group, laparoscopic sleeve gastrectomy appears to be an effective and safe first surgical approach for rapid weight loss in high-risk patients that require a second non-bariatric procedure.

A Hybrid Technique for Recurrent Incisional Hernia Repair

The aim of this technical report is to investigate the safety and effectiveness of a hybrid technique for recurrent incisional hernia repair, which combines the conventional and laparoscopic approaches. Six patients suffering from recurrent and complicated incisional hernias underwent a hybrid technique for their repair. The open part of the operation ensured extensive and safe adhesiolysis, reduction of the hernia content into the peritoneal cavity, and proper placement of the bowel loops into the peritoneal cavity, minimizing the risk of bowel perforation. For the laparoscopic part of the procedure, intraperitoneal (underlay) e-PTFE mesh placement, of the appropriate size covering the actual hernia size and the scar edges for at least 3 cm, was laparoscopically fixated by transfascial stay stitches, allowing stretch of the mesh on the anterior abdominal wall, probably avoiding the mesh deformation in the future. The overall size of the fascial defect was calculated between 116 and 187 cm, the size of the mesh used ranged from 308 to 468 cm, the total operative time ranged from 128 to 207 minutes and within a maximum follow-up period of 12 months, all patients are asymptomatic without any evidence of hernia recurrence. The hybrid technique is safe in cases of recurrent or complicated or difficult incisional hernias. A longer follow-up period is required to estimating the effectiveness and the cost-effectiveness of the method.

Sutureless mesh fibrin glue incisional hernia repair

The aim of this study is to evaluate the usefulness of sutureless incisional open hernia repair with mesh fixation only using a fibrin glue sealant. From 2002 to 2007, 40 patients underwent surgical recurrent incisional hernia repair, consisting of a sutureless positioning of a retromuscolar-preperitoneal polypropylene stiff mesh, fixed only with 2 ml of human fibrin glue. The average hospitalization period was 3 days; postoperative complications occurred in seven patients: wound infection in four patients and hematoma in three patients. Seroma was not observed. Postoperative pain occurred in two patients, while chronic pain occurred in one patient; the remaining 37 patients were pain-free. The use of an open retromuscolar mesh is an easy, inexpensive and relatively safe method to repair large incisional hernias. In our study the use of fibrin glue sealant demonstrated a low incidence of postoperative pain and short hospitalization.

Low recurrence rate of a two-layered closure repair for primary and recurrent midline incisional hernia without mesh

BackgroundIncisional hernia is a serious complication after abdominal surgery and occurs in 11–23% of laparotomies. Repair can be done, for instance, with a direct suture technique, but recurrence rates are high. Recent literature advises the use of mesh repair. In contrast to this development, we studied the use of a direct suture repair in a separate layer technique. The objective of this retrospective observational study is to assess the outcomes (recurrences and complications) of a two-layered open closure repair for primary and recurrent midline incisional hernia without the use of mesh.MethodsIn an observational retrospective cohort study, we analysed the hospital and outpatient records of 77 consecutive patients who underwent surgery for a primary or recurrent incisional hernia between 1st May 2002 and 8th November 2006. The repair consisted of separate continuous suturing of the anterior and posterior fascia, including the rectus muscle, after extensive intra-abdominal adhesiolysis.ResultsForty-one men (53.2%) and 36 women (46.8%) underwent surgery. Sixty-three operations (81.8%) were primary repairs and 14 (18.2%) were repairs for a recurrent incisional hernia. Of the 66 patients, on physical examination, three had a recurrence (4.5%) after an average follow-up of 2.6 years. The 30-day postoperative mortality was 1.1%. Wound infection was seen in five patients (6.5%).ConclusionsA two-layered suture repair for primary and recurrent incisional hernia repair without mesh with extensive adhesiolysis was associated with a recurrence rate comparable to mesh repair and had an acceptable complication rate.

Risk of Complications From Enterotomy or Unplanned Bowel Resection During Elective Hernia Repair

Enterotomy or unplanned bowel resection (EBR) may occur during elective incisional hernia repair (IHR) and significantly affects surgical outcomes and hospital resource use. Retrospective review of patients undergoing IHR between January 1998 and December 2002. Sixteen tertiary care Veterans Affairs medical centers. A total of 1124 elective incisional hernia repairs identified in the National Surgical Quality Improvement Program data set. Elective IHR. Thirty-day postoperative complication rate, return to operating room, length of stay, and operative time. Of the 1124 elective procedures, 74.1% were primary IHR, 13.3% were recurrent prior mesh IHR, and 12.6% were recurrent prior suture. Overall, 7.3% had an EBR. The incidence of EBR was increased in patients with prior repair: 5.3% for primary repair, 5.7% for recurrent prior suture, and 20.3% for prior mesh repair (P < .001). The occurrence of EBR was associated with increased postoperative complications (31.7% vs 9.5%; P < .001), rate of reoperation within 30 days (14.6% vs 3.6%; P < .001), and development of enterocutaneous fistula (7.3% vs 0.7%; P < .001). After adjusting for procedure type, age, and American Society of Anesthesiologists class, EBR was associated with an increase in median operative time (1.7 to 3.5 hours; P < .001) and mean length of stay (4.0 to 6.0 days; P < .001). Enterotomy or unplanned bowel resection is more likely to complicate recurrent IHR with prior mesh. The occurrence of EBR is associated with increased postoperative complications, return to the operating room, risk of enterocutaneous fistula, length of hospitalization, and operative time.

Laparoscopic Approach to Recurrent Incisional Hernia Repair: A 3-Year Experience

Incisional hernias are one of the most frequent complications of open abdominal surgery. The incidence of relapses after a conventional repair procedure is higher in recurrent than in primary cases (30%-50% vs. 11%-20%). The laparoscopic approach can prevent the complications associated with the conventional approach when dealing with recurrent incisional hernias. The aim of this study was to evaluate the efficacy of laparoscopic treatment in such cases. We prospectively analyzed data from 41 consecutive patients with recurrent incisional hernias, who submitted to a laparoscopic repair procedure with an expanded polytetrafluoroethylene Dual Mesh (Gore-Tex Dual Mesh Plus Biomaterial; W.L. Gore 8 Associates) from December 2001 to December 2004. All of the patients underwent clinical follow-up at 1, 6, and 12 months and then yearly. An ultrasound scan of the abdominal wall was performed at 6 and 12 months after the procedure. The parameters considered for the analysis were: mesh size, operating time, hospital stay, postoperative complications, and recurrences. The defects were usually localized along midline laparotomies. The mean mesh size was 400 cm2, the mean operating time was 68 minutes, and the mean length of hospital stay was 2.7 days. Complications were encountered in 17% of patients. The mean follow-up was 38 months (range, 18-54). Recurrence was reported in 1 case only (2.4%), which occurred within the first 6 months after the operation. The laparoscopic repair of recurrent incisional hernia seems to be an effective alternative to the conventional approach, as it can give lower recurrence and complication rates.

Repair of large complex recurrent incisional hernias with retromuscular mesh and panniculectomy

Background Recurrent incisional hernia repair is associated with high recurrence and wound complication rates. Methods The clinical courses of patients who underwent recurrent incisional hernia repair via retromuscular mesh placement with concomitant panniculectomy at a university teaching hospital from 1999 to 2004 were reviewed retrospectively. Postoperative evaluation included a quality of life survey. Results Forty-seven patients (13 male, 34 female) with an average body mass index of 34.4 kg/m 2, an average midline hernia defect of 31.4 cm, and at least 1 and on average 2.5 previous repair attempts underwent hernia repair. Wound infections occurred in 4 patients (8%) and seromas requiring aspiration occurred in 1 patient (2%). Four patients (8%) had re-recurrences of their hernias. All patients rated the postoperative appearance of their abdomen as at least satisfactory. Conclusions Recurrent incisional hernia repair with a retromuscular mesh and panniculectomy has low recurrence and wound complication rates and excellent patient satisfaction.

Obesity-Related Factors in the Repair and Healing of Recurrent Incisional Hernia: A Summary of Risk Factors and Perioperative Strategies

Recurrent incisional hernias are a clinical and surgical challenge in obese patients. In addition to tension on the repair created by abdominal girth, poor wound healing and immobility also contribute to recurrence in these patients. Specific postoperative nursing care strategies to prevent complications in complex hernia repairs are discussed. Surgical considerations including concomitant repair of hernia with bariatric surgery, panniculectomy, and individual care planning are also discussed.

INCISIONAL HERNIA AND ITS REPAIR WITH POLYPROPYLENE MESH IN RENAL TRANSPLANT RECIPIENTS

We evaluate the incidence of incisional hernia after kidney transplantation, predisposing factors and the results of surgical repair with polypropylene mesh. We reviewed the records of 371 consecutive kidney transplants performed between April 1995 and February 2000. Patients with clinical signs of hernia at the transplant incision site were included in the study. Predisposing factors for incisional hernia were also reviewed. A prospective protocol of surgical correction was established using polypropylene mesh and patient outcome was studied. We identified 14 patients (3.8%) with an incisional hernia at the transplant incision site. Hernias developed 3 to 840 days after transplant surgery and were significantly more common in white (p = 0.019) and cadaveric graft (p = 0.02) recipients. Predisposing factors in 11 cases included complications of transplant surgery in 7, bladder obstruction in 2, large polycystic kidneys in 1 and chronic pulmonary disease in 1. Surgical repair was performed by primary fascial approximation and polypropylene mesh reinforcement in 13 cases and by pre-peritoneal mesh placement in 1. Minor subcutaneous wound infection developed in 1 patient. No relapses were noted at a mean followup of 17.8 months. In the majority of cases incisional hernia develops in the first 3 months after transplant surgery. The incidence is significantly higher in white patients and after cadaveric donor transplantation. Surgical complications of transplant surgery are important predisposing factors for incisional hernia after kidney transplantation. Surgical repair using polypropylene mesh is safe and effective in this group of patients.

Recurrence after incisional hernia repair: results and risk factors.

A relatively low success rate in recurrent incisional hernia repair has prompted us to review the effects of certain risk factors on the long-term outcome of our cases. In this study, 109 recurrent incisional hernias were repaired and reviewed between 7 and 92 months after the operation. The recurrence rate was 45.0%. Many conditions that have been implicated as causal factors in the occurrence of incisional hernias were not found to be associated with recurrence after repair. However, chronic constipation was determined to be the most prominent risk factor associated with late recurrence.

Repair of recurrent ventral hernias by an internal “binder”

A technic for the repair of massive recurrent incisional hernia is described. Use of a polypropylene mesh prosthesis as an intraperitoneal “binder” permits reconstruction of the abdominal wall when primary closure is impossible. Intraoperative testing of the repair provides reassurance that unrestricted postoperative activity will not invite recurrence.