Repair Of Small Ventral Hernias Research Articles

S041-Trends and short-term outcomes of three approaches to minimally invasive repair of small ventral hernias. An ACHQC analysis.

Different approaches and mesh positions are used for minimally invasive ventral hernia repair (MIS-VHR).Our aim was to evaluate the trends and short-term outcomes of intraperitoneal onlay mesh (IPOM), preperitoneal, and retromuscular repairs for small ventral hernias. We conducted a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC). We included elective MIS-VHR in adults with hernia defect width < = 6cm from 2012 to 2021. We compared patient/hernia characteristics, trends, and short-term outcomes between IPOM, preperitoneal, and retromuscular repairs. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. A total of 7261 patients were included (IPOM = 4484, preperitoneal = 1829, retromuscular = 948). Preperitoneal repair was associated with lower rates of incisional (preperitoneal = 37%, IPOM = 63%, retromuscular = 73%) and recurrent hernias (preperitoneal = 11%, IPOM = 21%, retromuscular = 22%) compared to IPOM and retromuscular. Median defect width was 3.0, 2.0, and 4.0cm for IPOM, preperitoneal, and retromuscular, respectively. There has been a progressive increase in the proportion of preperitoneal and retromuscular repairs over time (10% in 2013-53% in 2021 of all MIS-VHR). Robotic approach was more frequently utilized in preperitoneal and retromuscular (both > 85%) compared to IPOM (47%). Transversus abdominis release was performed in 14% of retromuscular repairs. After IPTW, no clinically significant differences were noted in the short-term outcomes between IPOM versus preperitoneal. Retromuscular repairs were associated with higher risk of 30-day reoperation (OR = 3.54, 95%CI [1.67, 7.5] and OR = 5.29, 95%CI [1.23, 22.74]) compared to IPOM and preperitoneal repairs, respectively, and higher risk of 30-day readmission compared to preperitoneal repairs (OR = 2.6, 95%CI [2.6, 6.4]). Based on ACHQC data, preperitoneal and retromuscular approaches for MIS-VHR of small hernias have increased over time and are primarily performed robotically. Transversus abdominis release was performed in 14% of retromuscular repairs of these small hernias. Retromuscular repairs were associated with higher 30-day readmission and reoperation rates compared to the other approaches.

Single Center Observational Study to Evaluate the Safety and Efficacy of Self-expanding Composite Mesh for Repair of Small Umbilical Hernias

Background: There is evidence that mesh repair for umbilical hernias results in fewer recurrences. Early and late complication rates of mesh repair are variable with different techniques of mesh repair. In recent years, several mesh device for the repair of small ventral hernias have been developed, but some reports have been published reporting some adverse outcomes like high recurrences or wound related complications encountered with those mesh devices. The purpose of this study was to evaluate the safety and efficacy of small umbilical hernia(&lt;3cm) repair using self expanding dual mesh.&#x0D; Methods: In this study we used a composite self-expanding mesh with Polypropylene(PP) on one side and expanded polytetrafleuroethylene(ePTFE) on the other side. We introduced this technique in our department at BIRDEM General Hospital and IMC in March 2017 and collected patients data and outcome in an observational study of 25 consecutive patients matching our inclusion criteria until February 2019. In addition to the routine 1st week postoperative follow-up, We did a prospective follow-up at 1 month,6 month and 1 year which included a questionnaire, clinical examination and ultra sonogram after 12 months.&#x0D; Results: The study included 15 female and 10 male patients with age ranging from 25-62 years(Mean- 47) having 16 primary umbilical hernia and 9 umbilical port hernias. The size of gap was &lt;3cm and all except 2 hernias were reducible. In all patients a self expanding dual mesh was used with a diameter of 8cm(18 patients) or 6.4(7 patients) cm. Early complications included superficial wound infection-1(4%), seroma-1(4%), serosanguinous discharge-1(4%) and ecchymosis-1(4%). No major wound problems were noted in 1 month or 6 month follow-up except 1 patient reporting hypertrophied scar. At 1st month follow up 21 patientswere pain free, after 6 month only 1 patient reported mild pain, after 1 year 100% patients were pain free. 24 out of 25 patients ie 96% were very satisfied with the result of their repair. There was no recurrence after one year.&#x0D; Conclusion: Umbilical and umbilical port hernia repair with Self expanding dual mesh is effective and is cosmetically very appreciated by patients as good as laparoscopic repair. Therefore, we recommend using these meshes only for umbilical and umbilical port hernias smaller than 3 cm. For larger or incisional hernias other techniques allowing the use of larger meshes is advocated.&#x0D; Journal of Surgical Sciences (2020) Vol. 24 (2) : 43-50

Laparoscopic Repair of Small Ventral Hernias Using the "Ventralex™ Hernia Patch".

Laparoscopy of abdominal wall defects becomes more and more actual, considering the well-known advantages of minimally invasive surgery, and the reduced incidence of post-operative ventral infections and recurrence rates compared to the the open repair with or without mesh. We hereby present the technique of the laparoscopic repair of small ventral hernias (defect 2 centimetres), using the Ventralex mesh, which is bi-faceted, polypropylene and PTFE, circular preformed, it has 8 centimeters in diameter, fixated with 4 transparietal sutures. The mesh is created for open surgery but it is placed in the intraperitoneal cavity. This technique was used for 28 patients,16 women and 12 men, with an average age of 53,3 years (29-72 years), consisting of: 22 umbilical hernias (UH), 2 epigastric hernias (EH), one left-side Spiegelian hernia, one incisional hernia after an open surgery for an umbilical hernia with a Ventralex mesh, and 2 trocar eventrations (TE) after a laparoscopic cholecystectomy. Mean operating time was 52 minutes (42-70 minutes), post-operative hospital stay of 1,8 days (1-5 days). The main advantages are: circular preformed mesh, diameter of 8 centimeters, transfascial suture fixation, correct mesh placement and unfolding may be verified by laparoscopy, reduced costs. The technique is easy to reproduce.

Single centre observational study to evaluate the safety and efficacy of the Proceed™ Ventral Patch to repair small ventral hernias

There is evidence that mesh repair for primary umbilical hernias results in less recurrences and similar wound complication rates compared to tissue repair. In recent years, several mesh devices for the repair of small ventral hernias have been developed, but some reports have been published on serious complications and adverse effects encountered with those mesh devices. The Proceed™ Ventral Patch (PVP™) is a partially absorbable lightweight polypropylene mesh. We introduced PVP™ in our department in April 2009 and collected patient data and outcome in an observational study of 101 consecutive patients until December 2011 (Clinical.Trials.gov: NCT01307696). In addition to the routine control 3weeks postoperative, prospective follow-up included a questionnaire, clinical investigation and ultrasound after 12months. The study included 91 primary (76 umbilical/15 epigastric) and 10 incisional ventral hernias (including 6 trocar hernias). In all patients a PVP™ with a diameter of 6.4cm was used. Wound problems were the most frequent complication (n=18). Follow-up of at least 12months was achieved in 98 patients (97%) and the mean follow-up time was 15.9months. Follow-up by clinical examination diagnosed a recurrence in 11/92 patients (12.0%). Only four patients were aware of their recurrent hernia, the seven others reported no problems in the questionnaire. The additional ultrasound performed did not reveal recurrences that were not already diagnosed by clinical examination. In five patients a reoperation for repair of the recurrence was performed (reoperation rate 5/98=5.1%). Hernia defect size (p=0.032) and type of hernia (p=0.029) were found to be a significant risk factors for development of a recurrent hernia (Fisher's exact test). Hernia size was a significant risk factor both in a univariate (p=0.005) and in a multivariate Cox model (p=0.017). Incisional hernia was of borderline significance in a univariate (p=0.047) and in a multivariate Cox model (p=0.08). Intensive clinical follow-up yields a high percentage (12.0%) of clinically proven, but often asymptomatic recurrences after repair of small ventral hernias with the PVP™. Reoperation rate for recurrence was 5.1%. Hernia defect size is a significant risk factor for recurrence. Therefore, we recommend using the PVP™ only for primary ventral hernias smaller than 2cm. For larger or incisional hernias other techniques allowing the use of larger meshes is advocated.

Comparison of Laparoscopic Primary and Open Primary Repair of Ventral Hernias

Prosthetic materials have gained popularity for ventral hernia repair. There are situations when the use of a mesh is either unnecessary or contraindicated. This study compares 51 patients with ventral hernia who underwent laparoscopic or open primary suture repair. Results were determined by a median follow-up of 33 months. Recurrence rates and operative time were the major parameters of outcome. Mean operative time was insignificantly shorter in the laparoscopic group (14.8 ± 4.3 vs. 15.6 ± 3.7 min). There were no short-term complications in groups. One patient in each group had recurrence. Conclusively, laparoscopic primary repair of small ventral hernias is simple and can be performed as an initial approach for small defects. Compared with open repair, it has the advantages of better exposure, reduced pain, and less morbidity. It can also be performed as a component of a combined laparoscopic operation. However, this technique is not recommended for repair of large ventral hernias.

Laparoscopic Evaluation Shows Deficiencies in Memory Ring Deployment During Small Ventral Hernia Repair

To the Editor I congratulate Frederik Berrevoet and collaborators for their recent publication in World Journal of Surgery [1]. The repair of small ventral hernias in 28 patients was performed with a self-expanding, memory-containing reinforcement polypropylene/expanded polytetrafluoroethylene (ePTFE) patch and objectively assessed by simultaneous laparoscopic evaluation. The results were very disappointing, showing inadequate positioning of the hernia patch at laparoscopy in the majority of the cases and a 14.8% recurrence rate after a median follow-up of 25 months. There are few points that I would like to raise. Repair of small umbilical and ventral hernias based on the open underlay technique has become very popular as it is quick and easy to perform, offering the benefits of having the prosthesis placed behind the abdominal wall, while at the same time avoiding an unnecessary, more invasive, and costly laparoscopic approach. Unfortunately, the downside is the potential risk of developing intraperitoneal meshrelated complications, such as formation of dense adhesions or mesh erosion into the small bowel. This happened in one of their patient only two weeks postoperatively, and therefore was most likely related to a technical error. I believe that the size of the hernia patch is the main limitation in this approach. The larger the patch, the higher the risk of getting ‘‘cupping’’ of the mesh as the positioning straps are pulled up for fixation. Such cupping increases the exposure of the polypropylene side of the mesh. In their study, Berrevoet et al. used a large hernia patch (8 cm in diameter) in 86% of their cases and a mediumsized patch (6.4 cm) for the remaining procedures. In comparison, over the last 4 years I have used the identical prosthesis on 66 patients, but a large size mesh in only 15% of the cases (unpublished data). Although these hernia repairs were not controlled laparoscopically, I did not encounter any recurrence or major complication at a median follow-up of 20 months. A recent study, also using smaller size hernia patches, showed similar results [2]. Nevertheless, in light of the findings of Berrevoet et al., and to conclude, I recommend placing the mesh in the retromuscular or preperitoneal space rather than intraperitoneally. Should that placement not be practicable, my next suggestion would be to avoid using the large size prosthetic patch, unless it is possible to secure its edge safely to the abdominal wall, thus avoiding the above-described cupping effect.

Abdominal wall hernia repair with a composite ePTFE/polypropylene mesh: clinical outcome and quality of life in 152 patients

No consensus has yet been reached regarding the optimal mesh for the repair of small ventral hernias. A composite polytetrafluoroethylene/polypropylene mesh (Ventralex(®)) is designed for this purpose, and this paper reports its use in a larger series of patients. Open repair for a small ventral hernia was undertaken in 152 patients between April 2006 and June 2008. Data from medical files were gathered, and follow-up questionnaires were retrieved. Patients were asked about pain, intake of analgesics and various physical capabilities. Patients with postoperative complaints were offered a follow-up visit. Ultrasonography was performed if recurrence was suspected. Median surgery time was 39 min (range 16-129 min). Junior surgeons performed 63% of the operations. Questionnaires were returned by 81.6% with a mean follow-up of 15.6 months. Eighteen patients (11.8%) had complications. Pain score was significantly lower and the physical capabilities of the patients were significantly enhanced after the operation. Recurrent hernia was reported in four patients (2.6%). Five patients (3.3%) had the mesh removed due to deep infection, chronic pain or early recurrence. The training level of the surgeon had no influence on the incidence of complications. A 93.8% majority of the patients would recommend this specific procedure to others. The intraperitoneal placement of this composite mesh is associated with a high level of patient satisfaction as well as low rates of both recurrence and infection.

Open intraperitoneal versus retromuscular mesh repair for umbilical hernias less than 3cm diameter

Background Mesh techniques are the preferable methods for repair of small ventral hernias, as a primary suture repair shows high recurrence rates. The aim of this prospective study was to compare the retromuscular sublay technique with the intraperitoneal underlay technique for primary umbilical hernias. Methods From February 2004 to April 2007, all patients treated for umbilical hernias with maximum diameters of 3 cm were prospectively followed. During the first period of 15 months, all patients were treated with retromuscular repair using a large pore mesh (Vypro). After that period, for all patients, mesh repair using an intraperitoneal Ventralex patch was performed. All patients underwent general anesthesia. This analysis included 116 patients, of whom 56 had retromuscular repair (group I; mean age, 54.8 years; mean body mass index, 28.2 kg/m 2) and 60 had open intraperitoneal repair (group II; mean age, 48.1 years; mean body mass index, 29.4 kg/m 2). Operating time was evaluated as skin-to-skin time, and drain management was noted for both techniques. Follow-up was ≥2 years for all patients, and both early and late complications were registered, including seroma and hematoma formation, wound infection, fistula formation, and recurrence rates. Preoperative and postoperative pain was evaluated using a visual analogue scale (range, 0–10) on the day of the first outpatient visit; on postoperative days 1, 7, and 21; and after 1 year. Quality of life was estimated using the EQ-5D questionnaire 1 year after surgery. All data were analyzed using SPSS version 15 software. Wilcoxon's rank-sum test was used to analyze continuous variables, and repeated-measures analysis of variance was used for visual analogue scale scores. The χ 2 test and Fisher's exact test were used to assess the differences between categorical data. P values < .05 were considered statistically significant. Results The mean operative times were 79.9 minutes in group I and 33.9 minutes in group II ( P < .001). The mean hospital stay was significantly longer in group I (3.8 vs 2.1 days, P < .001). Seromas and superficial wound infections in the early postoperative period were not different between both groups, although seromas occurred more frequent in the retromuscular group. Postoperative visual analogue scale scores were significantly lower with the intraperitoneal technique at all time points ( P < .003, repeated-measures analysis of variance). However, 3 patients with the Ventralex patch had to be readmitted for severe pain. The recurrence rate was higher with the intraperitoneal repair (n = 5 [8.3%] vs n = 2 [3.6%]) than for the retromuscular mesh repair, but not statistically significant. Quality of life was comparable in the two groups after 1 year. Conclusions The open intraperitoneal technique using a Ventralex mesh for umbilical hernias seems a very elegant and quick technique. However, possibly because of the less controllable mesh deployment, recurrence rates seem higher. In case open mesh repair is the preferred treatment, a retromuscular repair should be the first choice.

Open Intraperitoneal Mesh Repair for Umbilical Hernias A Technical Note

Background: Mesh techniques are the preferable methods for repair of small ventral hernias, including umbilical and epigastric hernias, as primary suture repair shows high recurrence rates. Recently, the Ventralex™ (Davol Inc., C.R.Bard, Inc., RI, USA) hernia patch was introduced with promising preliminary short-term results. Methods: In this short technical note we describe both the surgical technique for adequate patch placement and the material characteristics of this device with associated pro’s and con’s.Conclusion: For small ventral hernia repair the Ventralex™ patch is a very elegant and quick to use mesh device. Although it is meant to be used intraperitoneally, it is also possible to place the patch in the preperitoneal space. However, probably due to the less controllable mesh deployment, and the interaction between the different materials, especially in the preperitoneal space, extra attention and some caution during placement is warranted using this device.