Sublay Mesh Placement Research Articles

Short-Term Outcomes of Umbilical Hernia Repair with Cirrhosis and Ascites

Background: Umbilical hernia is a popular disease, especially in patients with cirrhosis and ascites. The high and prolonged intra-abdominal fluid leads to increased intra-abdominal pressure, which causes the hernia to grow rapidly and cause complications. The clinical manifestations are mainly two: signs of hernia and symptoms of cirrhosis and ascites. The diagnosis of this condition is relatively simple, based mainly on clinical findings, and sometimes supported by imaging techniques. Umbilical hernia management in patients with cirrhosis and ascites has shifted towards early surgical repair to avoid complications. Two techniques of hernia reconstruction are available: simple suture and mesh implantation. Mesh-based methods are regarded as superior, but surgery in this population has many potential hazards and is still a surgical dilemma. This study examines the short-term outcomes of umbilical hernia reconstruction in patients with cirrhosis and ascites. Subjects – Methods: We conducted a retrospective study on 43 patients with cirrhosis and ascites who had umbilical hernia repair surgery at Cho Ray Hospital from January 2018 to December 2022. The surgery was either elective or emergency. We recorded the patient characteristics, surgical approaches, morbidity, and mortality. We followed up the patients for 30 days after the surgery. Results: The male: female ratio was 4:1. The average of age was 56.8 ± 10.7 years old (range: 27 – 79 years old). BMI was categorized into four groups: underweight in 9/43 cases (9.3%), normal in 22/43 cases (51.2%), overweight in 8/43 cases (18.6%), and obese in 9/43 cases (20.9%). All patients had a protrusion in the umbilicus when they were admitted to the hospital. Hernia pain and tenderness were present in 51.2% and 55.8% of the cases, respectively. 8/43 cases (18.6%) had complications of hernia rupture. The mean size of the hernia was 6.4 ± 5.1 cm (range: 2 – 30 cm). The patients underwent emergency surgery in 37/43 cases (86%). All surgeries were open, and the methods of hernia repair were simple suture in 35/43 cases (81.4%), onlay mesh placement in 4/43 cases (9.3%), sublay mesh placement in 1/43 case (2.3%), and preperitoneal mesh placement in 3/43 cases (7%). The mean operative time was 93 ± 37.2 minutes (range: 50-200 minutes). The mean hospital stay was 7 ± 3.2 days (range: 2 – 17 days). There were 13 cases with postoperative complications, accounting for 30%. 2 deaths occurred due to intra-abdominal bleeding and severe peritonitis. Conclusion: Umbilical hernia is a frequent complication in patients with ascites and cirrhosis. The diagnosis is mainly based on clinical signs, and imaging techniques are used in complicated cases that require further evaluation of the content and condition of the hernia sac. The patients have a high rate of complications and mortality after surgery, which are related to late surgery, degree of cirrhosis, and MELD score ≥ 20. Therefore, the patients need early diagnosis and surgery to avoid complications that affect their survival.

A morbidly obese patient with large incisional hernia managed with posterior compartment separation sub-lay mesh placement

Most of the incisional hernias are diagnosed in first 3 years after the major abdominal surgery but some may take 9-10 years before the presentation after surgery. Risk factors to develop incisional hernia includes patient factors; advanced age, hypertension, diabetes, obesity, anemia, smoking, chronic obstructive pulmonary disease (COPD), immunosuppression, previous coronary intervention, renal disease requiring dialysis, recent weight loss and malnutrition. Surgery related risk factors includes intraoperative complication, suture technique, surgical site infections, fascial dehiscence and other postoperative complications. We are presenting of large incisional hernia, which have managed with posterior compartment separation. Large incisional ventral hernias following abdominal surgeries can pose significant challenges in management and quality of life for both patients. The Rives-Stoppa repair technique provides authentic and essential solution for management of large complex ventral hernias with reducing the risk of recurrence and providing long-term support to the abdominal wall.

Strategies for closing the posterior rectus sheath during enhanced view totally extraperitoneal Rives-Stoppa repair.

The popularity of endolaparoscopic extraperitoneal repairs has been on the rise due to advantages such as sublay mesh placement and early return to daily activities. However, the procedure requires overcoming a learning curve, and with increased adoption, new complications have emerged. One significant complication is the rupture of the posterior rectus sheath (PRS). In this article, we present our modifications of the technique to reduce tension during PRS closure. The study included 105 patients who underwent endolaparoscopic extraperitoneal repairs for ventral hernias using two different techniques. Group A (n = 68) underwent the original technique, whereas Group B (n = 37) underwent the modified technique. The modifications in Group B included preserving the peritoneal bridge between the two PRS and the hernia sac, conducting a complete dissection of the space of Bogros and adopting a transverse or oblique closure of PRS along the lines of least tension. To assess the efficacy of these modifications in preventing PRS rupture, we compared the results of both groups. Our findings indicate that following all the technical steps of the modified technique resulted in a reduced need for transversus abdominis release for PRS closure and a lower incidence of PRS rupture in the postoperative period. However, to further validate the effectiveness of these modifications, a larger follow-up period and a bigger sample size are required. The adoption of the modified technique can help achieve a tension-free PRS closure.

The endoscopic-assisted or endoscopic mini- or less-open preperitoneal (E/MILOP) approach for primary and incisional ventral hernia repair.

The endoscopic-assisted or endoscopic mini- or less-open sublay (E/MILOS) concept describes a contemporary approach of trans-hernial repair of ventral hernia via sublay mesh placement. The term sublay often causes confusion, and preperitoneal placement of mesh should be considered as a distinctive approach. We hereby present our experience of a novel approach, the E/MILOP approach, for the repair of primary and incisional ventral hernias. All patients who underwent E/MILOP between January 2020 and December 2022 were identified and their preoperative and perioperative characteristics, as well as postoperative outcomes, were retrospectively analyzed. The surgical procedure entailed an incision over the hernia defect and careful entrance into, and development of, the preperitoneal space trans-hernially. A synthetic mesh was placed in the preperitoneal space and the defect was closed with sutures. A total of 26 patients with primary and/or incisional ventral hernias who underwent E/MILOP were identified. Three patients (11.5%) presented with two coexistent types of hernias, and out of a total of 29 hernias, there were 21 (72.4%) umbilical, four epigastric (13.8%) and four incisional (13.8%) hernias. The mean defect width was 2.7 ± 0.9 cm. All cases utilized a mesh with a mean mesh-to-defect ratio of 12.9. The mean postoperative stay was 1.9 days. Surgical site occurrence was observed in eight (30.1%) patients, but none required intervention. No recurrence was observed during a mean follow-up period of 286.7 days. The E/MILOP approach is a novel alternative for primary and incisional ventral hernia repair.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study.

Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair. A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program. One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5days for group 3 (p < 0.005). Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

V-009 ROBOTIC UMBILICAL HERNIA REPAIR WITH RETRORECTUS SUBLAY MESH AND PLICATION OF RECTUS DIASTASIS VIA THE TRANSABDOMINAL PREPERITONEAL (TAPP) APPROACH

Abstract Aim Umbilical hernias and rectus diastasis can greatly reduce patients’ quality of life, especially in this patient who is a professional athlete and coach. We present a robotic umbilical hernia repair with retrorectus sublay mesh and plication of rectus diastasis through the transabdominal preperitoneal (TAPP) approach. Material &amp; Methods Video recording from the operating room was included. In the recording, we demonstrate the steps of this robotic approach with clear visualization of anatomic structures. Results A 37-year-old male with an enlarging umbilical hernia with intermittent incarceration and associated rectus diastasis presented for repair due to a significant impact on his work and quality of life. The patient underwent a TAPP robotic repair of his umbilical hernia and plication of rectus diastasis with a retrorectus sublay mesh placement. This was a same-day discharge procedure that the patient tolerated without complications. Conclusions Umbilical hernias and associated rectus diastasis can effectively be repaired robotically with retrorectus sublay mesh through the TAPP approach.

An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair.

Purpose: Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods: A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results: Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects.Rives-Stoppa sublay mesh repair has become the “gold” standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature.Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned.Conclusions: Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.

A COMPARATIVE STUDY BETWEEN ONLAY AND SUBLAY MESH REPAIR IN THE MANAGEMENT OF INCISIONAL HERNIA

Background: An incisional hernia is one of the common complications of abdominal surgery and the incidence of incisional hernias continues to be 3 to 11% after laparotomy. The repair of incisional hernia has always been a challenge to the surgeon. Various operative techniques for the repair of incisional hernia are in practice; however, the management is not standardized. Aim: To compare onlay mesh placement versus sublay mesh placement in repair of incisional hernias. This prospective study Material and Methods: comprised of 50 patients with an incisional hernia. A total of 50 cases were included in the study. Of the 50 cases, 25 cases were operated by the onlay mesh method and 25 by sublay mesh placement. Results: The operative time for sublay mesh repair was signicantly higher than that of onlay mesh repair, whereas, complications like haemorrhage, seroma formation and deep surgical site infection leading to extrusion of mesh was higher in onlay mesh repair. The recurrence rate was found to be 4% in onlay mesh repair whereas it was 0% in sublay mesh repair. Sublay mesh repair, though technically difcult, Conclusion: and takes more time for surgery has the distinct advantage of reducing the rate of infection and recurrence.

Transversus Abdominis Release Versus Anterior Component Separation in Ventral Abdominal Hernia - A Prospective Comparative Study

Ventral abdominal hernia (VAH) repair is considered a surgical challenge especially hernias with large defect size and loss of domain (1-3). The incidence of recurrence after VAH repair ranges from 18.1% in primary VAH to 30.6% in secondary VAH (incisional hernia) (4). The principle of any hernia repair is to achieve a tension free repair with re-enforcement by mesh to decrease the incidence of recurrence (5). Many techniques had been studied and evaluated to address the problem of complex VAH with large defects and loss domain (1,6). In 1973, Rives et al. described their technique of retro rectus space dissection for incisional hernia (IH) repair allowing medial mobilization of myofascial flap and sub-lay mesh insertion (7, 8). But this technique has limitation in cases of large VAH as it doesn’t allow major myofascial advancement due to lateral limitation of linea semilunaris (LS) (9). In 1990, Ramirez et al. at described their technique of open anterior component separation (ACS) (10). In this technique, the external oblique aponeurosis is separated from internal oblique lateral to LS to achieve more medial mobilization of myofascial flap (9). ACS was successfully utilized in cases of large VAH, but the technique had its drawbacks. ACS was found to be associated with high rates of wound complications (seroma, wound infection, and flap necrosis) due to excess subcutaneous dissection with the possibility of lateral abdominal wall hernia at area of external oblique incision. The recurrence rate after ACS ranges from 9-18% (4). In 2012, Novitsky et al. were the first to describe the technique of posterior component separation and transversus abdominis release (PCS-TAR). The technique involved retro rectus space dissection reaching the LS, then an incision is made at posterior rectus sheath to access the space between internal oblique and transversus abdominis muscles. Dissection is carried on in this space until reaching psoas muscle laterally. This technique has the advantage of allowing maximum medial myofascial mobilization without major subcutaneous dissection. In addition, the technique allows for sub-lay mesh placement (11). All these different component separation techniques aim to reestablish a functional abdominal wall through autologous tissue repair by separating between myofascial layers of anterior abdominal wall (AAW). This allows medial mobilization of myofascial flap to obliterate large size defects (12-14). Due to the relative novelty of these techniques, a knowledge gap still persists regarding which CS technique is suitable to different types of VAH. The aim of our study is to compare the outcomes of TAR with ACS as regard short term postoperative complication and recurrence rate.

Preperitoneal space, is it an ideal layer for endoscopic sublay repair of ventral hernia?

Preperitoneal space, is it an ideal layer for endoscopic sublay repair of ventral hernia?

P050 INTRODUCTION OF MINIMAL INVASIVE PROCEDURES WITH EXTRAPERITONEAL MESH PLACEMENT MAY REDUCE MORBIDITY AND LENGTH OF HOSPITAL STAY IN PATIENTS WITH INCISIONAL HERNIA - A SINGLE CENTER'S EXPERIENCE

Abstract Aim “Sublay mesh placement is the gold standard in the treatment of incisional hernias. In open surgery, high rates of wound complications are reported. Various minimal invasive procedures with extraperitoneal mesh placement (MIPEX) are currently under evaluation in order to improve the clinical results. We report our experience with an increased use of MIPEX techniques” Material and Methods “The perioperative results of all consecutive patients from 1/2018 to 4/2021with incisional hernia surgery were reviewed. For the purpose of this study, the results of patients with MIPEX were compared to STANDARD treatment (open surgery and/or intraperitoneal mesh). All patient data were registered prospectively in the Herniamed database. ” Results “103 out of 170 patients were treated with MIPEX and 67 with STANDARD. MIPEX were MILOS/E-MILOS (n = 48), TAPP (n = 15), laparoscopic sublay (n = 5), ETEP (n = 17) and other (n = 18) with additional TAR in (n = 16). Five procedures were performed robotically. Mean duration of surgery (DOS) was 150 minutes in MIPEX and 116 minutes in STANDARD (n.s.). Morbidity was 7% in MIPEX and 19% in Standard (p &amp;lt; 0.5). Mean length of hospital stay (LHS) was 4 days in MIPEX and 8 days in STANDARD (p &amp;lt; 0.5). In subgroup analysis of patients with large hernias (EHS-3, n = 31), DOS was 320 minutes (MIPEX) vs. 159 minutes (STANDARD); p &amp;lt; 0.01 and LHS was 8 days (MIPEX) vs. 12 days (STANDARD), p &amp;lt; 0.01.” Conclusions “MIPEX included a broad spectrum of procedures. With the implementation of MIPEX, DOS increased significantly in large hernias. Morbidity and LHS were significantly reduced in all patients.”

Association between surgical hernia repair techniques and the incidence of seroma: a systematic review and meta-analysis of randomized controlled trials.

Ventral hernia repair (VHR) includes the surgical reconstruction of the abdominal wall (AW) using different surgical techniques. Although such procedures are usually devoid of complications, the formation of seroma may frequently occur. We performed a systematic review to assess the evidence from randomized controlled trials (RCTs) comparing VHR techniques and their impact on seroma formation. We included RCTs having seroma formation as primary endpoint. We included patients of both sexes (age > 18). For data synthesis we applied a random-effects model and calculated risk ratios (RR) with 95% confidence intervals (CI) using the Mantel-Haenszel method. Risk of bias (ROB) and publication bias were evaluated following Cochrane recommendations. After database search and article screening, 21 records were included in this review. Ten RCTs compared onlay vs. sublay mesh placement techniques. Pooled analysis showed a significantly higher risk ratio for seroma in the onlay cohort (RR = 2.61, 95% CI 1.86-3.66, I2 = 0, GRADE quality of evidence, moderate). Five RCTs compared laparoscopic intraperitoneal onlay mesh repair vs. open mesh placement. Pooled analysis showed that seroma formation did not differ significantly between groups (RR = 1.91, 95% CI 0.69-5.28, I2 = 66%, GRADE quality of evidence, poor). High ROB was found in all studies and significant publication bias was detected in both meta-analyses. Compared to sublay ventral hernia repair, the onlay procedure is associated with a significantly higher risk of seroma. No significant differences were observed when laparoscopic VHR was compared with the open surgical procedure. Due to the diversity of surgical techniques reported in includedRCTs, it is currently not possible to draw conclusive clinical recommendations. Future studies should be standardized to provide detailed data allowing thorough evaluation of the impact of the evidence on clinical practice.

Preventing Hernia Recurrence: Optimising Mesh Use in Incisional Hernia Repair

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

Laparoscopic Trans-Abdominal Retromuscular (TARM) Repair for Ventral Hernia: A Novel, Low-Cost Technique for Sublay and Posterior Component Separation

BackgroundThe complications of intraperitoneal onlay mesh repair for ventral hernia has favored sublay mesh placement like open Rives–Stoppa repair (ORS). There was a need for low-cost laparoscopic trans-abdominal repair using a polypropylene mesh (PPM) with sublay, midline closure and addition of posterior component separation (PCS) by transversus abdominis release (TAR).MethodsThe techniques used three or six operating ports with triangulation. After adhesiolysis, a transverse incision was made on the peritoneum (P) and posterior rectus sheath (PRS). The retromuscular space was developed by raising a P-PRS flap. Midline closure was performed with No. 1 polydioxanone, and a PPM was placed in sublay, followed by closure of defect and P-PRS incision. For large hernias with divarication; myo-fascial medialization using PCS-TAR aided low-tension midline closure.ResultsEighty-nine patients were operated from 2010 to 2019, 26 primary ventral; 63 incisional; and 22 recurrent hernias. Of the primary, 21 were umbilical, one Spigelian and four epigastric hernias. The incisional group had 57 patients with lower midline scars (C-section 25, open tubal ligation 15, abdominal hysterectomy 17), five lateral (appendicectomy), one post-laparotomy. The mean age, male/female sex ratio and BMI were 41.23 years, 1:10.1 and 29.2 kg/m2, respectively. Mean defect and mesh area were 110 cm2 and 392 cm2. Mean operating time was 192 min. Conversion to open, mesh infection and recurrence rates were 3.4%, 1.1% and 5.62%.ConclusionLaparoscopic TARM with PPM in sublay avoids mesh–bowel contact. It provides midline closure and PCS-TAR within the same port geometry with results comparable with ORS.

Original concepts in anatomy, abdominal-wall surgery, and component separation technique and strategy.

The abdominal wall can be considered comprised of two compartments: an anterior and a posterior compartment. The anterior compartment includes the anterior rectus sheath and the rectus muscle. The posterior compartment comprises the posterior rectus sheath, the transversalis fascia, and the peritoneum. When a large defect in the anterior compartment has to be corrected, for example, a rectus diastasis or large incisional hernia, an action on the anterior compartment is necessary; therefore, an anterior component separation has to be considered. If a loss of substance is present in the posterior compartment, a trasversus abdominis release should be accomplished. We propose an original anterior compartment mobilisation, by a posterior approach. Dissection of the posterior rectus sheet proceeds until the linea semilunaris is reached. Incision of the anterior rectus sheath permits a mobilisation of the anterior compartment by a posterior approach. A mesh is placed in a sublay position. If the abdominal wall presents a loss of substance of the posterior compartment, a transversus abdominis release (TAR) can be performed in the same time. No hernia recurrences, no wound infection, and no mesh infection have been reported. The anterior compartment mobilization permits mobilization towards the midline of rectus muscle and restoration of anterior compartment, with low morbidity rate; it can be easily associated to a large sublay mesh placement, it allows the preservation of the neurovascular bundles and rectus muscle trophism, and it can be associated with a concomitant TAR procedure for the restoration of the PC, if necessary.

A comparative study of onlay &amp; sublay mesh repair of ventral wall hernias in a tertiary care research centre

Introduction: Ventral hernia is common in abdominal surgeries and is an important source of morbidity and mortality. Range of surgical techniques has been developed, from suturing techniques to various types of mesh repair. Mesh repair technique has shown a less number of postoperative complications and recurrence compared with other techniques. The bed on which mesh is placed is still debated. Among which one type being onlay and other being sublay are widely used but outcome of both is still controversial and do depend on surgeon’s choice of procedure. The purpose of this study was to compare the traditional on?lay mesh and sublay mesh placement in ventral hernia repairs in terms of time taken for surgery, duration of post-operative drainage, early and delayed complications. Materials and Methods: This is a prospective study which was conducted in the surgical department Navodaya Medical college hospital and research centre. A total of 50 cases in 1 years of duration were studied. Of these cases, 25 cases were managed by the on?lay mesh method and 25 by sublay mesh placement. Results: Operative time for sublay mesh placement was significantly higher than on?lay mesh repair, whereas, the duration of post-operative suction drainage was significantly lower in case of the sublay group. Superficial surgical site infection and seroma formation were statistically insignificant in both the study groups, although lesser in the sublay group. The recurrence rate was found to be 11% in on?lay mesh repair and 7% in sublay (retro rectus) mesh repair. Conclusions: Sublay mesh repair seems to be better method than onlay repair in duration of the post-operative suction drainage. In the sublay mesh repair group lower rate of complications and recurrence were seen. Keywords: Onlay, Sublay, Mesh Repair, Ventral hernias.

A comparative study of on-lay and sub-lay mesh repair of ventral wall hernias in a tertiary health care centre

Background: Ventral hernia is a common occurrence in abdominal surgeries and an important source of morbidity. A wide spectrum of surgical techniques have been developed, ranging from suturing techniques to various types of prosthetic mesh repair. Use of mesh repair technique showed a reduced number of postoperative complications and recurrence compared with other techniques. The exact technique of mesh repair is still debated. The purpose of this study was to compare the traditional on‑lay mesh and sublay mesh placement in ventral hernia repairs in terms of time taken for surgery, duration of drainage after surgery, early complication and delayed complications.Methods: This is a prospective study which was conducted in the surgical department of our hospital. A total of 50 cases were included in this study. Of these cases, 25 cases were operated by the on‑lay mesh method and 25 by sublay mesh placement.Results: The operative time for sublay mesh placement was significantly higher than that of on‑lay mesh repair, whereas, the duration of post-operative suction drainage was significantly lower in case of the sublay group. Occurrence of complications like superficial surgical site infection and seroma formation were statistically insignificant in both the study groups, although frequency of complications was lesser in the sublay group. The recurrence rate was found to be 12% in on‑lay mesh repair and 8%in sublay(retro‑rectus) mesh repair.Conclusions: Sublay mesh repair is a better method than onlay repair with respect to the duration of the post-operative suction drainage. A lower rate of complications and a lower rate of recurrence was seen in the sublay mesh repair group.

Postoperative-treatment following open incisional hernia repair: A survey and a review of literature

IntroductionIncisional hernias of the abdominal wall are frequent complication after laparotomy (9–20%). Open incisional hernia repair with sublay mesh placement (SMP) on the posterior rectus sheath is described as being a sufficient method for repairing incisional hernia. In order to ensure wound healing and to therefore prevent recurrence, carrying an abdominal binder (AB) or a pressure dressing (PD) and physical rest for a certain time is the common postoperative recommendation, though the evidence for post-operative treatment is low. Hence, we conducted a survey to reveal the different recommendations given by surgical departments (SD). MethodsWe conducted a survey among 65 German SDs of the XXX Hospital Group. The SDs were interviewed about the number of open incisional hernia repair with SMP in the time frame of 2013–2014, the known recurrence rate (RR), their recommended prescription of the AB/PD and the time of physical rest. ResultsThe head physicians of 48 surgical departments answered the questionnaire. The survey revealed 42 different recommendations of postoperative-treatment. The majority of the SDs advices 4 weeks (20,5%) of physical rest and no prescription of the AB (29,5%). No correlation between the known RR and the duration of physical rest was detected. No head physician's prescribes a PD. ConclusionsDue to our findings we assume that a short period of physical rest is a considerable postoperative treatment following an open incisional hernia repair with SMP. By reducing the individual incapacity for work and immobility this would have a social-economic impact. The use of a PD may prevent seroma formation. Further investigations with randomized clinical trials are mandatory to support our hypothesis.

Abstract: Posterior Sheath Repair in Abdominal Wall Reconstruction: Achieving Retromuscular Mesh Placement

INTRODUCTION: Ventral hernia repair (VHR) remains a difficult surgical problem to manage. Retromuscular sublay mesh placement in VHR consistently provides favorable outcomes regardless of mesh type utilized, presumably highlighting the importance of the posterior rectus sheath. We hypothesized that posterior sheath repair to achieve retromuscular closure demonstrates improved outcomes compared to intraperitoneal repair as well as comparable recurrence and complication profiles to retromuscular sublay repair. METHODS: We performed a single-institution retrospective review over three-years of consecutive hernia repairs for two surgeons. Included patients were grouped according to repair-type: A) sublay placement with reconstructed posterior sheath, B) retromuscular repair with unaltered posterior sheath, and C) intraperitoneal or underlay repair. Primary outcome measures included hernia recurrence and surgical site occurrence (SSO). Analysis included multivariate logistic regression and descriptive statistics. RESULTS: One-hundred seventy-nine patients met inclusion criteria. There were 25 (14.0%) in Group-A, 89 (48.7%) in Group-B, and 65 (36.3%) in Group-C. Groups did not differ in average age 56.5 (p<0.298), BMI 32.4 (p<0.774), incidence of diabetes, hypertension, hyperlipidemia, COPD, tobacco use, OR time, or ostomy reversal. The majority of cases consisted of ASA class 3 (54.2%), Ventral Hernia Working Group (VHWG) class 2 (47.5%), and clean wound classification (63.7%). Prior hernia repairs were performed in 102 (57%) patients. Biologic mesh was used in 56 (31.3%) patients, synthetic in 103 (57.5%), and biosynthetic in 20 (11.2%). Patient post-operative follow-up averaged 15.5 months. Analysis of 11 recurrences yielded significant differences between Groups-B and C (p<0.009), a trend towards significance between Groups-A and C (p<0.058), and no difference between Groups-A and B (p<0.608). Retromuscular mesh placement and anterior components separation demonstrated protective effects on recurrence (OR: 0.148, p<0.081 and OR: 0.259, p<0.067). Postoperative mesh infection (OR: 72.03, p<0.012) and seroma (OR: 8.992, p<0.036) were significant predictors of hernia recurrence. BMI (OR: 1.052, p<0.015), VHWG (OR: 1.617, p<0.036), and hyperlipidemia (OR: 2.157, p<0.049) were significant predictors of SSO on multivariate regression. The posterior sheath was reconstructed primarily using absorbable suture for small defects, or biologic mesh for larger defects. CONCLUSION: Initial analysis of posterior sheath repair to allow for retromuscular VHR suggests noninferiority, when compared to traditional sublay reconstruction. We present the first known description of discrete posterior sheath reconstruction to aid in retromuscular closure of complex ventral hernia.

Onlay with Adhesive Use Compared with Sublay Mesh Placement in Ventral Hernia Repair: Was Chevrel Right? An Americas Hernia Society Quality Collaborative Analysis

The use of mesh during ventral hernia repair (VHR) is a well-accepted concept. However, the ideal location of mesh placement remains strongly debated. Although VHR with onlay mesh placement has historically been associated with a high rate of wound events, this surgical approach is technically less challenging than VHR with sublay mesh placement. The purpose of this study was to compare 30-day wound events after onlay mesh placement with adhesive fixation vs those after sublay mesh placement using the Americas Hernia Society Quality Collaborative database. All patients undergoing elective, open VHR with synthetic mesh placement from January 2013 through January 2016 were identified within the Americas Hernia Society Quality Collaborative. Only patients with clean wounds were included. Patients were divided into 2 groups: onlay mesh placement with the use of adhesive and sublay mesh placement. The association of mesh location with 30-day wound events was investigated using a matched analysis. A total of 1,854 patients met inclusion criteria; 1,761 (95.0%) underwent sublay mesh placement and 93 (5.0%) underwent onlay mesh placement with the use of adhesive. A 2:1 sublay to onlay matched analysis was performed based on factors previously shown to influence wound events after VHR. After matching, both groups had a lower mean Ventral Hernia Working Group grade and fewer associated comorbidities. There was no statistically significant difference between the sublay and onlay groups with respect to 30-day surgical site infections (2.9% vs 5.5%; p= 0.30), surgical site occurrences (15.2% vs 7.7%; p= 0.08), or surgical site occurrences requiring procedural intervention (8.2% vs 5.5%; p= 0.42). Ventral hernia repair with onlay mesh placement is a safe alternative to VHR with sublay mesh placement in low-risk patients. Additional studies are needed to determine the long-term mesh outcomes and recurrence rates in both of these groups.