Treatment Of Incisional Hernias Research Articles

Hernia Correction After Liver Transplantation Using Nonvascularized Fascia.

Liver transplantation is an increasingly frequent surgical procedure, with elevated rates of postoperative incisional hernias ranging from 5% to 46%. There are numerous known risk factors for incisional hernia, including the type of incision, patient sex, and presence of comorbidities such as diabetes, ascites, older age, and the use of steroids. Most studies on the treatment of incisional hernias in patients who have undergone liver transplantation have shown consistently high rates of complications. Consequently, we propose the use of nonvascular fascia for the symptomatic treatment of incisional hernias in patients with concomitant liver transplantation. We performed our new technique on 8 patients, who had previously undergone liver transplantation, between January 2019 and January 2023. The patients were examined using imaging techniques during the follow-up period. Of the 8 patients, 7 were liver transplant recipients and 1 was a combined liver-kidney transplant patient. The median donor age was 57 y (5-66 y), whereas the mean recipient age was 58 y (31-66 y). The median patient height and weight were 163 cm (117-185 cm) and 76 kg (17-104 kg), respectively. Immunosuppression did not change in fascia recipients. The median time between transplantation and hernia repair surgery was 41 mo (5-116 mo). The sizes of the aponeurotic defects varied from 6 × 6 to 25 × 20 cm. Two patients experienced complications: one experienced bulging that required reintervention and the other experienced surgical site seroma. There was no mortality related to the use of the technique, and none were reported during follow-up. With its promising results, nonvascularized fascial transplantation can be a successful treatment for incisional hernias in patients who had previously received a liver transplant.

First report of robotic retromuscular incisional hernia repair with Hugo Ras™ surgical system.

Treatment of incisional hernia is a rapidly evolving field of surgery, with actual trends being oriented toward retromuscular/preperitoneal mesh placement. The diffusion of robotic surgery is constantly growing in different surgical specialties and is gaining widespread acceptance for abdominal wall reconstruction. Recently, novel robotic platforms have entered into the market. In this study, we present the first transabdominal retromuscular incisional hernia repair performed with the new Hugo RAS™ system (Medtronic, Minneapolis, MN, USA). The surgical team had previous robotic experience and completed an official 2-day session running incisional hernia repair on human cadaver lab. Operating room setting and trocar layout were planned. The patient presented a 4 × 4cm midline incisional hernia and was scheduled for transabdominal retromuscular incisional hernia repair at our Institution. A description of the operative room setup, robotic arm configuration and docking/tilt angles is provided. Docking time, operative time, and console time were 15, 95, and 75min, respectively. All the surgical steps were completed without critical surgical errors or high-priority alarms. Neither intraoperative complications nor conversion to open surgery was recorded. Postoperative course was uneventful and the patient was discharged on postoperative day 2. The safety and the feasibility of these procedures will require further analysis and larger patients' sample sizes for procedural standardization and potential integration into minimally invasive abdominal wall reconstruction programs.

Chronic postsurgical pain (CPSP): an underestimated problem after incisional hernia treatment.

Chronic postsurgical pain (CPSP) is a potential long-term problem following open incisional hernia repair which may affect the quality of life of patients despite successful anatomical repair of the hernia. The aim of this manuscript was to identify the incidence and outcome of patients following open incisional hernia repair in respect of risk factors to develop CPSP. A single-center retrospective analysis of patients who underwent open incisional hernia repair between 2015 and 2021 was performed. Pre-existing conditions (e.g., diabetes mellitus and malignancy), hernia complexity, postoperative complications, and postoperative pain medication were analyzed using the local database. Quality of life and CPSP were assessed using the EuraHS Quality of Life (QoL) questionnaire. A total of 182 cases were retrospectively included in a detailed analysis based on the complete EuraHS (QoL) questionnaire. During the average follow-up period of 46 months, this long-term follow-up revealed a 54.4% incidence of CPSP and including a rate of 14.8% for severe CPSP (sCPSP) after open incisional hernia surgery. The complexity of the hernia and the demographic variables were not different between the group with and without CPSP. Patients with CPSP reported significantly reduced QoL. The analgesics score which includes the need of pain medication in the initial days after surgery was significantly higher in patients with CPSP than in those without (no CPSP: 2.86 vs. CPSP: 3.35; p = 0.047). The presence of CPSP after open incisional hernia repair represents a frequent and underestimated long-term problem which has been not been recognized to this extent before. CPSP impairs QoL in these patients. Patients at risk to develop CPSP can be identified in the perioperative setting by the need of high doses of pain medication using the analgesics score. Possibly timely adjustment of pain medication, even in the domestic setting, could alleviate the chronicity or severity of CPSP.

Roboticassisted incisional hernia surgery-Retromuscular techniques

The trend to minimally invasive surgery has also made its way into the surgical treatment of incisional hernias. Unlike other areas of visceral surgery, recent years have seen aresurgence of open sublay repair in incisional hernia procedures, primarily due to the recognition of the retromuscular layer as the optimal mesh placement site. Additionally, with the growing availability of robotic systems in visceral surgery, these procedures are increasingly being offered in the form of minimally invasive procedures. These methods can be categorized based on the access routes: robotic-assisted transperitoneal procedures (e.g., r‑Rives, r‑TARUP, r‑TAR) and total extraperitoneal hernia repair (e.g., r‑eTEP, r‑eTAR). Notably, the introduction of transversus abdominis muscle release enables the robotic-assisted treatment of larger and more complex hernia cases with complete fascial closure. With respect to the comparison with open surgery required in retromuscular hernia treatment, the currently available literature on incisional hernia repair seems to show initial advantages of robotic-assisted surgery in the perioperative course. New technologies create new possibilities. In the context of surgical training the use of surgical robot systems with double consoles opens up completely new perspectives. Furthermore, the robot enables the implementation of models of artificial intelligence and augmented reality and could therefore open up novel dimensions in surgery.

Measurements of abdominal wall defect and hernia sac volume in the treatment of incisional hernia: Application of ultrasonic volume auto-scan in 50 cases.

Abdominal incisional hernia is one of the most common complications after surgery. The preoperative evaluation of the area of abdominal wall defect and the hernia sac volume(HCV) is very important for the selection of patch size and incisional herniorrhaphy. Meanwhile the overlap range of reinforcement repair is controversial. This study aimed to explore the value of ultrasonic volume auto-scan(UVAS) in the diagnosis, classification and treatment of incisional hernia. Both the width and the area of abdominal wall defect and HCV were measured by UVAS in 50 cases with incisional hernias. In 32 of these cases, the measurements of HCV were compared with those of CT. Classification of incisional hernia based on ultrasonic images were compared with operative diagnosis. The measurements of HCV by UVAS and CT 3D reconstruction had good consistency, of which the mean ratio was 1.0084. According to the location and width of abdominal wall defect, UVAS, which showed good accuracy rate (90%, 96%), reached a good agreement in the classification of incisional hernias with operative diagnoses (Kappa=0.85, Confidence Interval [0.718,0.996]; Kappa=0.95, Confidence Interval [0.887,0.999]). The patch area should be at least two times as large as the defect area. UVAS is an accurate alternative to measure the abdominal wall defect and HCV and classify the incisional hernia, with additional benefits of no radiation exposure and instant bedside interpretation. The use of UVAS is conducive to preoperative assessment of the risk of hernia recurrence and abdominal compartment syndrome.

Mini- or less-open sublay (E/MILOS) operation vs open sublay and laparoscopic IPOM repair for the treatment of incisional hernias: a registry-based propensity score matched analysis of the 5-year results.

Open sublay and laparoscopic IPOM repair have specific disadvantages and risks. In recent years, this evidence led to a paradigm shift and induced the development of new minimally invasive techniques of sublay mesh repair. Pioneering this trend, we developed the endoscopically assisted mini- or less-open sublay (MILOS) concept. The operation is performed trans-hernially via a small incision with light-holding laparoscopic instruments either under direct, or endoscopic visualization. After dissection of an extra-peritoneal space of at least 8cm, port placement and CO2 insufflation, each MILOS operation can be continued endoscopically (EMILOS repair). All E/MILOS operations were prospectively documented in the Herniamed Registry with 1- and 5-year questionnaire follow-ups. Propensity score matching of incisional hernia operations comparing the results of the E/MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from all other institutions participating in the Herniamed Registry was performed. The results with perioperative complications and 1-year follow-up have been published previously. This paper reports on the 5-year results. The 5-year follow-up rate was 87.5% (538 of 615 patients with E/MILOS incisional hernia operations). Comparing E/MILOS repair with laparoscopic IPOM and open sublay operation, propensity score matching analysis was possible with 448 and 520 pairs of operations, respectively. Compared with laparoscopic IPOM incisional hernia operation, the E/MILOS repair is associated with significantly fewer general complications (P = 0.004), recurrences (P < 0.001), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.016) and tends to result in fewer postoperative complications (P = 0.052), and less pain at rest (P = 0.053). Matched pair analysis with open sublay repair revealed significantly fewer general complications (P < 0.001), postoperative complications (P < 0.001), recurrences (P = 0.002), less pain at rest (P = 0.004), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.014). A limitation of this analysis is a relative low 5-year follow-up rate for laparoscopic IPOM and open sublay. The E/MILOS technique allows minimally invasive trans-hernial repair of incisional hernias using large standard meshes with low morbidity and good long-term results. The technique combines the advantages of sub-lay repair and a mini- or less-invasive approach. ClinicalTrials.gov Identifier NCT03133000.

Prevention of incisional hernia after kidney transplantation: study protocol for a randomized controlled trial

BackgroundIncisional hernia is a common complication after kidney transplantation with an incidence of 1.6–18%. Concerning non-transplant patients, a recently published meta-analysis describes a reduction of the incidence of incisional hernia of up to 85% due to prophylactic mesh replacement in elective, midline laparotomy. The aim of our study is to show a reduction of the incidence of incisional hernia after kidney transplantation with minimal risk for complication.Methods/designThis is a blinded, randomized controlled trial comparing time to incisional hernia over a period of 24 months between patients undergoing kidney transplantation and standardized abdominal closure with or without prophylactic placement of ProGrip™ (Medtronic, Fridley, MN, USA) mesh in an onlay position. As we believe that the mesh intervention is superior to the standard procedure in reducing the incidence of hernia, this is a superiority trial.DiscussionThe high risk for developing incisional hernia following kidney transplantation might be reduced by prophylactic mesh placement. ProGrip™ mesh features polylactic acid (PLA) microgrips that provide immediate, strong and uniform fixation. The use of this mesh combines the effectiveness demonstrated by the macropore propylene meshes in the treatment of incisional hernias, a high simplicity of use provided by its capacity for self-fixation that does not increase significantly surgery time, and safety.Trial registrationClinicalTrials.gov NCT04794582. Registered on 08 March 2021. Protocol version 2.0. (02–18-2021).

Incidence, Risk Factors, and Management of Incisional Hernias After Kidney Transplant: A 20-Year Single Center Experience

Incisional hernias (IH) constitute a complication after kidney transplant (KT). Patients may be particularly at risk because of comorbidities and immunosuppression. The study aim was to assess the incidence, risk factors, and treatment of IH in patients undergoing KT. This retrospective cohort study included consecutive patients who underwent KT between January 1998 and December 2018. Patient demographics, comorbidities, perioperative parameters, and IH repair characteristics were assessed. Postoperative outcomes included morbidity, mortality, need for reoperation, and length of stay (LOS). Patients who developed IH were compared with those who did not develop one. Forty-seven patients (6.4%) developed an IH after a median delay of 14 months (IQR, 6-52 months) in 737 KTs. On uni- and multivariate analyses, body mass index (odds ratio [OR], 1.080; P=.020), pulmonary diseases (OR, 2.415; P=.012), postoperative lymphoceles (OR, 2.362; P=.018), and LOS (OR, 1.013; P=.044) were independent risk factors. Thirty-eight patients (81%) underwent operative IH repair, and 37 (97%) were treated with a mesh. The median LOS was 8 days (IQR, 6-11 days). Three patients (8%) developed surgical site infections, and 2 patients (5%) presented hematomas requiring surgical revision. After IH repair, 3 patients (8%) had a recurrence. The incidence of IH after KT seems rather low. Overweight, pulmonary comorbidities, lymphoceles, and LOS were identified as independent risk factors. Strategies focusing on the modifiable patient-related risk factors and early detection and treatment of lymphoceles may help to decrease the risk of IH formation after KT.

Different cellular and immunohistochemical abdominal wall cicatrization parameters evaluation in comparison with sublay, onlay, and ipom technique in an experimental rat model.

Incisional hernia (IH) occurs when there is a partial or complete solution of continuity of a fascia previously incised. Systematic reviews demonstrate that surgical treatment of IHs with the use of meshes are approximately 16%. Meta-analyses have demonstrated the superiority of mesh placement using sublay technique, but without a pathophysiological explanation. Thus, we aim to evaluate the different techniques of mesh positioning in an experimental model. Fifty rats were distributed into five groups; control; simulation (SM)-submitted to laparotomy only; onlay-the mesh was positioned in onlay fashion; retromuscular (SL)-the mesh was positioned in a sublay fashion; intraperitoneal (IPOM)-positioning of the mesh adjacent to the transversalis fascia, inside the cavity. After 60days, adhesions, tensiometry, histology, and immunohistochemistry were addressed. The IPOM group had the most adhesions, together with the SL group, with significantly relevant results. The SL group had higher values of tensiometric evaluation, while the IPOM group had the lowest mean in the tensiometry evaluation, being even lower than the SM group. Regarding histological and immunohistochemical findings, the SL group had a higher pixel number count compared to the groups, with statistical significance, in addition to higher expression of polymorphonuclear infiltrate and CD68 markers. The mesh positioning in sublay compartment is associated with the development of more pronounce minimum tensile force required for detaching the surrounding abdominal wall tissues it was incorporated. The intensity of these findings correlates to the different histological and immunohistochemical profiles observed following each repair, since SL group was characterized by a higher proportion of collagen, inflammatory, and reparative elements. Characterizing these pro-healing elements and its counterparts will allow the development of new therapeutic tools which could be added to the still far-from-ideal current therapeutic options for IH treatment.

Two-Stage Abdominal Wall Reconstruction in a Patient with a Complex Postoperative Hernia

Surgical treatment of incisional hernia is an actual problem of abdominal surgery. Despite the improvement of surgical techniques, the results of surgical treatment cannot be considered satisfactory: the recurrence rate continues to be high and is due to failures in the reconstruction of complex ventral hernia. Although there are many works devoted to various aspects of the surgical treatment of patients with complex incisional hernias, the problem is not sufficiently resolved. The treatment of this category of patients is a difficult task for both surgeons and patients due to the high risk of general and local complications. A clinical case of surgical treatment of a patient with a complex incisional hernia is presented, in which it was possible to carry out a complete reconstruction of the anterior abdominal wall in two stages without "components separation" method.

НОВЫЙ МЕТОД ПЛАСТИКИ ПОСЛЕОПЕРАЦИОННЫХ ВЕНТРАЛЬНЫХ ГРЫЖ: СРАВНИТЕЛЬНОЕ ЭКСПЕРИМЕНТАЛЬНОЕ ИССЛЕДОВАНИЕ

The problem of incisional hernia has become widespread due to the increase in the amount of laparotomies in abdominal surgery. After laparotomy in 4-11% cases incisional hernias occurred, which makes the problem one of the most important in abdominal and plastic surgery. The research aim is to experimentally evaluate and compare the absolute strength, increase in strength and reaching tensile strength of abdominal wall tissues after surgical treatment of incisional hernia with two different methods: Sapezhko and modified Sapezhko, the latter involving placing the mesh in the double abdominal layer. Material and methods. At the first stage of the study, incisional hernia was modeled in 36 rats. Consequently, the animals were divided into two groups. The main group consisted of 18 rats and underwent the Sapezhko surgical treatment of incisional hernia. The control group of 18 remaining rats underwent modified Sapezhko surgical treatment. On days 10, 14 and 16 the animals were taken out of the experiment. Strength of native abdominal walls of 6 rats were examined. The strength of the parts of abdominal walls was measured on the universal testing machine. Results. The findings indicate that polypropylene mesh placed in the double layer of the abdominal wall induces tighter scar formation in comparison with scars in the double layer of abdominal wall without mesh. Conclusions. The results of experimental research show that newly developed method have statistically significant advantages on the absolute strength, increase in strength and reaching tensile of strength of abdominal wall tissues.

P-120 LAPAROSCOPIC REPAIR OF INCISIONAL HERNIA USING A NON-ABSORBABLE TRANSPARENT COMPOSITE PROSTHESIS TOTALLY IN POLYPROPYLENE - OUR EXPERIENCE

Abstract Introduction Incisional ventral hernia is one of the most common surgical complications after laparotomy. The aim of this retrospective observational study is an evaluation of clinical outcomes after laparoscopic repair of incisional hernias with a non-absorbable and transparent composite prosthesis composed of a macro-porous monofilament polypropylene mesh and a transparent polypropylene film. Materials and Methods 63 patients, from January 2016 to December 2021, were treated for incisional hernia at Center of minimal invasive surgery Nis, Serbia. The mesh was always positioned intraperitoneally after closing the defects and fixed with absorbable tacks and non-absorbable suture. Results In the considered cohort (54% female and 46% male) the median age and BMI were 54 years (range: 39–68) and 25,1 kg/m2 (range: 21.5–30.3), respectively. Concerning hernia position, 93.7% of the hernias were medial, 4.8% lumbar and 1.6% medio-lumbar. According to EHS classification, 58.7% of the hernias were W1, 36.5% W2 and 12.7% W3. The average duration of hospitalization was 2 days. The rate of early post-operative complications was 6.3%, including 1 seroma (1.6%) and 3 patients reporting pain (4.8%). At a median follow up of 48 months (range: 6–60) we registered 2 cases of hernia recurrency (3.2%, both at 36 months follow-up) and 1 case of bowel obstruction (1.6%). All the considered variables did not result statistically significative in relation to post-operative complications. Conclusion Our clinical experience showed that intraperitoneal treatment of incisional hernia using a transparent composite prosthesis. The minimally invasive procedure allows a fast postoperative recovery and a consequent low economical cost.

Collagen Deposition and Inflammatory Response Associated with Macroporous Mesh Shrinkage in Incisional Hernia Repair: A Rat Model

Background: Mesh repair is the current recommendation for the treatment of incisional hernia; however, the best mesh has yet to be determined. The objective of this study was to compare the inflammatory response and collagen deposition in primary incisional hernia repair (P) and different macroporous mesh materials, including polypropylene with poliglecaprone (PP-PG), polyvinylidene fluoride (PVDF), and polyester (PE), using quantitative methods. Methods: Sixty male rats were divided into four groups. Anterior abdominal wall defects were created and either suture or mesh repair was done. Rats were euthanized on days 14, 90, and 180, and the gross findings were recorded. The inflammatory and collagen levels in the abdominal wall tissues were measured using enzyme-linked immunosorbent assay (ELISA). Results: The PE group demonstrated significant mesh shrinkage at 180 days. The extent of PE mesh shrinkage ranged from 22–42% (mean = 30.49%). At 14 days, the PVDF group had higher interleukin-6 (IL-6) levels than the PP-PG (P = .004) and PE groups (P = .019). At 90 days, the collagen type I (Col I) levels in the PE group were significantly lower than those in the others, and the collagen type I/III (Col I/III) ratios in the PE group were lower than those in the P group (P = .006). Conclusions: The persistently high IL-6 levels until 180 days and the decrease in Col I levels and Col I/III ratio at 90 days seem to predict mesh shrinkage at 180 days. The mesh induces high Col I levels, but those associated with low Col III levels should be preferred.

Bowel perforation on recurrent incisional hernia after laparoscopic repair; case report and literature review

IntroductionIncisional hernias are located on the site of a previous incision and are due to weakness of the abdominal wall. In years past, the risk of developing an incisional hernia after laparotomy was 25%. This figure has decreased significantly in recent decades thanks to the laparoscopic technique (Hoffman et al., 2021 [1]), but complications occasionally occur.Case presentationWe describe a case of recurrent incisional hernia with bowel perforation in a 58-year-old man who had undergone laparoscopic cholecystectomy 8 years previously and who required repeated laparoscopic procedures. After multiple attempts at closing the hernia, the patient complained of acute abdominal pain located in the right flank. The patient proved to suffer a bowel perforation one month after the surgery.DiscussionDue to the lack of similar cases, it was difficult to prevent the bowel perforation. Moreover, opinions are divided on the treatment of incisional hernia by prosthesis, especially if there is an infectious context. Bowel perforation can be a serious complication of incisional hernia repair. In our case, the delay was suggestive of an idiopathic origin of the condition, which is rare and less described.ConclusionIn the literature, bowel perforation due to laparoscopic adhesiolysis during incisional hernia repair has been described. However, in the current case the complication was most likely directly related to the incisional hernia repair itself.

Incisional Hernia Repaired Using Thigh Muscle Fascia After Kidney Transplantation: A Case Report

Although monofilament mesh-based repair is a safe and effective procedure for incisional hernia (IH) in organ transplant patients, there is no definite evidence of IH treatment for patients with graft rejection and enhanced immunosuppressive therapy. We report a successful case of large IH repair using an autologous thigh muscle fascia sheet in a kidney transplant patient. A 69-year-old man had IH from the incision of kidney transplantation, which was performed 6 years ago. He had a large right lower abdominal distension hanging down to the inguinal portion. A computed tomography scan revealed a large IH with a maximum abdominal defect diameter of 15 cm. The hernia sac contained the intestine, colon, and transplanted kidney, which had pulled out along with the retroperitoneum and protruded into the abdominal wall. He had chronic active acute antibody-mediated rejection, which required frequent steroid pulse therapy and additional or adjusted immunosuppressive drugs. After total circumferential exposure of the hernia sac and abdominal fascia, the abdominal wall defect was closed using a horizontal mattress suture. The sutured line was covered with a thigh muscle fascia sheet harvested from the patient's right femur and attached to the closed fascia. He was discharged on postoperative day 13 without any complications, and no IH recurrence was observed 10 months after surgery. Hernia repair using autologous tissue could be a treatment option for post-transplant IH with a higher risk of infection.

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.”

P023 MANAGEMENT OF MASSIVE INCISIONAL HERNIA WITH LOSS OF DOMAIN

Abstract Aim Large incisional hernia treatment is challenging for surgeons especially when there is loss of domain. Its management require an appropiate preoperative optimization of the patient. We present a complex case that provides an exhaustive review of different measures in order to treat this type of hernias. Material and Methods A 61-year-old, smoker and diabetic patient consulted because of a large ventral hernia. He underwent an umbilical hernia surgery which recurred three more times. The patient had a M1-M5 W3 hernia with active suppuration through fistulous orifices. The abdominal wall planning CT scan showed a large eventration with 23 cm of transverse defect diameter and a Tanaka index of 92%. Results The patient received support to quit smoking and he lost weight due to an intragastric balloon. Botulinum toxin was administered six weeks before surgical intervention. An andominal pneumeperitoneum catheter was placed, reaching 12.400 liters of ambient air insufflated during 13 days. Finally, surgery was performed, finding a 27 x 35 cm wall defect that required the performance of: After these maneuvers, the posterior abdominal wall could be completely closed. A double preperitoneal mesh (BioA and polypropylene) was placed. After 16 days, he was discharged without mayor complications. Conclusions Loss of domain hernias are a complex entity which requires a multidisciplinary approach and abdominal wall experienced surgeons since it may require extreme measures.

Analysis of Factors Relevant to Revenue Improvement in Ventral Hernia Repair, Their Influence on Surgical Training, and Development of Predictive Models: An Economic Evaluation.

Background: Ventral hernia repairs (VHR) are frequent but loss- making. This study aims to identify epidemiological and procedure related factors in VHR and their influence on surgical training. Methods: Data from 86 consecutive patients who underwent VHR in 2019 was collected. Moreover, 66 primary ventral hernias and 20 incisional hernias were repaired in open procedures. Linear regression models were made. Results: Primary VHR procedures showed a mean deficit of −378.17 CHF per case. Incisional hernia repair procedures resulted in a deficit of −1442.50 CHF per case. The two hernia groups were heterogeneous. For the primary VHR procedures, the surgery time (β = 0.564, p < 0.001) had the greatest influence, followed by the costs of the mesh (β = −0.215, p < 0.001). The epidemiological factors gender (β = 0.143, p < 0.01) and body mass index (BMI) (β = −0.087, p = 0.074) were also influential. For incisional hernia procedures a surgeon’s experience had the most significant influence (β = 0.942, p < 0.001), and the second largest influence was the price of the mesh (β = −0.500, p < 0.001). The epidemiological factor BMI (β = −0.590, p < 0.001), gender (β = −0.113, p = 0.055) and age (β = −0.026, p < 0.050) also had a significant influence. Conclusion: Our analysis shows a way of improving financial results in the field of ventral hernia repair. Costs can be visualized and reduced to optimize revenue enhancement in surgical departments. In our analysis primary ventral hernias are an appropriate training operation, in which the experience of the surgeon has no significant impact on costs. In primary VHR procedures, revenue enhancement is limited when using an expensive mesh. However, the treatment of incisional hernias is recommended by specialists. The financial burden is significantly higher with less experience. Therefore, these operations are not suitable for surgical training. The re-operation rate decreases with increasing experience of the surgeon. This directly affects the Patient Related Outcome (PROM) and quality of treatment. Therefore, high-quality training must be enforced. Since financial pressure on hospitals is increasing further, it is crucial to investigate cost influencing factors. The majority of Swiss public hospitals will no longer be able to operate ventral hernias profitably without new concepts. In addition to purchasing management, new construction projects, and mergers, improving the results of individual departments is a key factor in maintaining the profitability of hospitals in the future regarding hernia repair without losing the scope of teaching procedures.

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

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

Trentino Hernia Team Technique Plus Endoscopic Transversus Abdominis Release for Large Ventral Incisional Hernias: Description of the First Case

Trentino Hernia Team Technique Plus Endoscopic Transversus Abdominis Release for Large Ventral Incisional Hernias: Description of the First Case