Underlay Mesh Research Articles

The Evolving Applications of Laparoscopic Intracorporeal Rectus Aponeuroplasty (LIRA) in Ventral Hernia Repair-A Systematic Review.

Laparoscopic intracorporeal rectus aponeuroplasty (LIRA), emerged as a method that combines benefits from minimally invasive and abdominal wall reconstruction with defect closure, restoring the midline without tension by folding the posterior aponeurosis of both abdominal rectus muscles and using intraperitoneal mesh repair. We aimed to perform a systematic review of the existing evidence on LIRA results and potential applications. A thorough search of Cochrane Central, Scopus, SciELO, LILACS, and PubMed/MEDLINE, focusing on studies that explored LIRA's possible applications and results was performed. Key outcomes evaluated included recurrence, seroma, hematoma, surgical site infection (SSI), and length of hospital stay. We included both analytic data and descriptive studies. Out of 128 screened studies, three met the inclusion criteria and comprised 113 patients, of which 69 (61.1%) were operated using LIRA. Three studies comprised two case series of conventional and robotic LIRA repair, and one comparative study of LIRA versus intraperitoneal underlay mesh repair (IPUM plus). No surgical site infections were reported. Seroma rates ranged between 11.1% and 50%, while no bleeding or hematoma was noted. There were no patients presenting recurrence in a median follow-up ranging from 12 to 15months, despite the comparative study reporting a 4.4% rate of bulging without clinical recurrence. The mean length of hospital stay ranged from 12 to 36h. LIRA presented no differences in postoperative complications compared to the IPUM plus technique. LIRA is linked to low recurrence and postoperative complications. It is a novel approach with potential applications in various types of primary and incisional ventral hernias.

SMALL BOWEL OBSTRUCTION AS A COMPLICATION OF TRANSABDOMINAL PREPERITONEAL HERNIA REPAIR – AN INTERNAL HERNIA CAUSED BY ADHESIONS TO A BARBED SUTURE

Abstract Background Laparoscopic approach to inguinal hernias is advantageous as it reduces postoperative pain, length of stay and recovery time, while allowing for an easier correction of multiple hernia defects in a single operation. Laparoscopic transabdominal preperitoneal (TAPP) hernioplasty is one such technique. Bowel obstruction as a postoperative complication is rare, and can be due to inadequate peritoneal closure, herniation through disrupted peritoneum or adhesions. Aim We herein report on a case of postoperative small bowel obstruction caused by adhesions to a long, barbed suture. Material and Methods Case presentation, in video format, of a 74-year-old man admitted through the emergency department for small bowel obstruction, 7 days after laparoscopic bilateral TAPP hernioplasty and intraperitoneal underlay mesh (IPUM+) hernioplasty for correction of bilateral inguinal hernia and umbilical hernia. Results After examination, and an inconclusive computerised tomography scan, the patient underwent emergency laparoscopic exploration. We found a small bowel obstruction caused by adhesions to the barbed suture previously used to close the peritoneal flap on the right side. The small bowel was freed from the suture, without need for its resection. Appendicectomy was performed as well. The patient was discharged 3 days later, without further complications. Conclusions Adhesions after peritoneal closure may lead to postoperative small bowel obstruction. Surgeons must be aware of complications associated with any procedures performed, including the rare, since a timely diagnosis is necessary for their patients’ adequate care. Hernia surgeons can minimise this complication by improving their suture technique and avoiding bridges of exposed barbed sutures.

Investigation of optimal hernia repair techniques in patients with inflammatory bowel disease.

Multiple laparotomies, immunosuppressive therapy, wound infection, and malnutrition are risk factors for incisional hernia development, which places inflammatory bowel disease (IBD) patients at high risk. With advances in minimally invasive techniques, this study assesses incisional hernia repair techniques and complications in the IBD population. A single-center, retrospective review of adults with IBD who underwent incisional hernia repair from 2008 to 2022. Complications relative to operative approach and mesh placement location were assessed using descriptive and univariate statistics. Eighty-eight IBD patients underwent incisional hernia repair. Fifty-two (59.1%) were on immunomodulators and 30 (34.1%) were repaired primarily. Thirty-five (39.7%) hernias recurred, of whom 19 (33%) had mesh placed. Three (30%) occurred in onlay repairs and 16 (33%) occurred in underlay repairs. Subdivision of underlay repairs into intraperitoneal, preperitoneal and retrorectus mesh placement revealed recurrence rates of 35.1%, 50%, and 14.3%, respectively. Patients with open repair were more likely to have intraoperative bowel injury (28.6% vs 9.7%, p = 0.041) and develop postoperative seromas/abscesses (12.5% vs 0%, p = 0.001) and wound complications (17.9% vs 0%, p = 0.012) compared to laparoscopic. Seromas/abscesses developed more frequently in onlay repairs compared to underlay (40% vs 2.13%, p = 0.001). Twelve (13.6%) patients presented with postoperative small bowel obstruction (SBO), 7 (58.3%) of whom had mesh placed, and 6 (85.7%) were underlay. All SBO after underlay repair had intraperitoneally placed mesh. When comparing surgeons, hernias were more likely to recur performed by colorectal surgeons compared to hernia surgeons (63.3% vs 21.3%, p < 0.001). In IBD patients, minimally invasive approaches lead to fewer perioperative complications compared to open. Underlay mesh placement demonstrated decreased incidence of seroma/abscess formation compared to onlay. When sub-grouped, underlay placements were similar in terms of complications. Retrorectus placement, however, had fewer recurrences and no readmissions for SBO. This suggests a minimally invasive approach or placement of retrorectus mesh may provide the optimal repair in this patient population.

Robotic Intracorporeal Rectus Aponeuroplasty: Early Experience of a New Surgical Technique for Ventral Hernia Repair.

Introduction: The laparoscopic intracorporeal rectus aponeuroplasty (LIRA) was developed as an alternative for minimally invasive ventral hernia repair. This technique allows the closure of the defect and restoration of the midline without tension by plication of both aponeurosis of the abdominal rectus muscles combined with a minimally invasive intraperitoneal underlay mesh repair. The objective of this study is to report our early experience with the Robotic-LIRA (R-LIRA) technique and its safety and short-term efficacy. Methods: We performed a retrospective analysis of patients undergoing R-LIRA repair for ventral hernias from March 2019 to April 2022. Results: Eight patients underwent R-LIRA from March 2019 to April 2022. Median age was 47 years (interquartile range [IQR] 34.5-62.8). Median body mass index was 34.2 kg/m2 (IQR 29.9-35.2). Four patients (50%) had a primary ventral hernia being one M2, two M3, and one M2/M3. There were three incisional hernias, being one recurrent, 6 patients (75%) had associated diastasis of the rectus muscle and 1 patient presented pure diastasis. The median hernia width was 4 cm (IQR 2-6), and the median defect area was 16 cm2 (IQR 4-42). The median mesh area was 290 cm2 (IQR 211.2-300). In all cases, a barbed suture was also used for mesh fixation, and tackers were added in 4 cases. The median operative time was 172 minutes (IQR 139.8-293.3). The median length of stay was 0.5 days (IQR 0-1.8), and the median follow-up was 20 days (IQR 16-46). Conclusion: The R-LIRA has been shown to be safe and feasible for ventral and incisional hernia repairs with or without Diastasis of the Rectus Abdominis Muscle in the short term.

Comparative study between the sublay versus onlay techniques of mesh hernioplasty in case of ventral hernias

Background: Abdominal hernias are common surgical conditions that can be presented as emergency and elective surgeries. Ventral hernia repair has always been a major challenge for surgeons. The mesh hernioplasty method has been considered the golden option for preventing or minimizing the incidence of recurrence, but the question is where surgeons should place the mesh or onlay. Objective: To compare the onlay versus sublay technique for ventral hernia in terms of performance and outcome. Methodology: Prospective study (120) of patients undergoing ventral hernia repair. We collect our cases for three years from (May 1, 2017 to May 2020) and will continue until (January 2022). Sixty patients were treated with onlay mesh repair (group A) and 60 patients were treated with underlay mesh repair (group B). Data collected in both groups were performed with respect to operative time, placement, and time required for drain removal, wound infection, and recurrence rate. Follow-up was performed every three months for 24 months. Data were analyzed using SPSS version 18, Fisher's exact test as appropriate; a p-value less than 0.05 was considered statistically significant.Results: In the sublay group, seroma formation was found in two patients (3.33%), while in 12 (20%) in the onlay group. Wound infection was found in one patient (1.66%) in the sublay group and 6 (10%) in the onlay group. no septic mesh was removed in the sublayer group, one mesh was removed in the onley type. In the onlay group, recurrence was found in 4 patients (6.66%), while no recurrence occurred in the sublay group. Conclusion: Sublay mesh hernioplasty is a better alternative to onlay mesh hernioplasty for all forms of ventral hernias.

1630 Laparoscopic Repair of Linea Arcuata Hernia Presenting as Generalised Abdominal Pain - a Case Report

Abstract Background Arcuate line hernia (LAH) is an abnormal ascending herniation of intraperitoneal structures over the linea arcuate, between the rectus abdominus muscle and the posterior layer of its sheath. It is a rare clinical entity often associated with non-specific abdominal pain, posing a significant diagnostic challenge. The true prevalence is unknown, and diagnosis is almost always radiological. Case Report We report the case of a 57-year-old lady investigated extensively for frequent episodes of generalised abdominal pain. No palpable hernial defect or other pathology was identified on clinical examination. Subsequent computed tomography(CT) of the abdomen and pelvis revealed a 95 x 74 mm arcuate line hernia(LAH) anterior to the transversalis fascia, containing small bowel loops. She underwent an elective laparoscopic repair involving closure of the hernial defect with 2-0 knotless barbed sutures and reinforcement with a 20 x 15 cm underlay mesh. Postoperative recovery was uneventful, with complete resolution of her symptoms. One year after the repair there were no signs of recurrence. Discussion To our knowledge, only eleven prior cases of symptomatic LAH have been reported in the literature. There is no conclusive evidence regarding most appropriate diagnostic imaging, treatment approach and follow up regimen. Clinical diagnosis is difficult. Existing literature suggests use of CT scan as the primary imaging modality for diagnosis. The laparoscopic approach is safe, feasible and has certain advantages. This includes confirmation of diagnosis, excludes the presence of concomitant hernias and enables inspection of herniated viscera. Prosthetic mesh reinforcement is considered to minimise recurrence. Long term follow-up of these patients is required

Incisional Hernia Incidence, Repair Techniques, and Outcomes Based on 1600 Consecutive Patients Receiving Abdominally Based Autologous Breast Reconstruction.

As the number of postmastectomy patients who receive abdominally based autologous breast reconstruction (ABABR) increases, the frequency of unique paramedian incisional hernias (IHs) at the donor site is increasing as well. We assessed incidence, repair techniques, and outcomes to determine the optimal treatment for this morbid condition. A total of 1600 consecutive patients who underwent ABABR at the University of Pennsylvania between January 1, 2009, and August 31, 2016, were retrospectively identified. Preoperative and operative information was collected for these patients. Incisional hernia incidence was determined by flap type and donor site closure technique. Repair techniques and postoperative outcomes for all patients receiving IH repair (IHR) after ABABR at our institution were also determined. Univariate and multivariate analyses were conducted. The incidence of IH after ABABR in our health system was 3.6% (n = 61). Fifteen additional patients were referred from outside hospitals for a total of 76 patients who received IHR. At the time of IHR, mesh was used in 79% (n = 60) of cases (13 biologic and 47 synthetic), with synthetics having significantly lower recurrent IH incidence (10.6% vs 38.5%, P = 0.017) when compared with biologics. Mesh position did not have any statistically significant effect on outcomes; however, sublay mesh position had zero adverse outcomes. Mesh should be used in all cases when possible. Although retrorectus repair with mesh is optimal, this plane is often nonexistent or too scarred in after ABABR. Thus, intraperitoneal underlay mesh with primary fascial closure or primary closure with onlay mesh placement should then be considered.

Application of double circular suturing technique (DCST) in repair of giant incision hernias.

BackgroundOur study aims to explore the feasibility and safety of a double circular suturing technique (DCST) in the repair of giant incision hernias.MethodsThe clinical data of 221 patients (95 men and 126 women; the average age was 61.6 years) receiving DCST in the repair of giant incision hernia between January 2010 and December 2018 was analyzed retrospectively. One hundred and five primary and 16 recurrent patients underwent herniorrhaphy with anti-adhesion underlay mesh repair using DCST.ResultsAll the 221 operations were performed successfully. The average preparation time before the operation and hospital stays were 3.7 days (range, 1–6 days) and 7.5 days (range, 2–16 days), respectively. The average diameter of the hernia ring defect observed intraoperatively was 16.4 cm (range, 12–22 cm). The average time of operation was 83.6 min (range, 43–195 min). There were 2 cases of intestinal fistula, 4 cases of wound infection, 2 cases of mesh infection, 7 cases of serum tumescence, 3 cases of pulmonary infection, and 2 cases of wound dehiscence occurred. One hundred and ninety-five patients were followed up for 6.7 years (range, 0.8–9.5 years) postoperatively. Of them, 9 patients recurred; 14 patients had chronic pain whose visual analog scale (VAS) was 2–4 cm (average 2.7 cm).ConclusionsWith limited preparation time before operations, few postoperative complications, and recurrence rate, DCST in the repair of giant incision hernia is safe and possible clinically.

Application of double circular suturing technique (DCST) in the repair of large abdominal wall defects after resection of abdominal wall tumor.

BackgroundThe aim of this study was to investigate the clinical effects of repairing large defects using the double circular suturing technique (DCST) after resection of abdominal wall tumor.MethodsThe clinical data of 62 patients (25 men, 37 women; average age 41.7±22.4 years) who underwent DCST between October 2010 and November 2018 for the repair of large abdominal wall defects with anti-adhesion underlay mesh after resection of abdominal wall tumor were retrospectively analyzed. The maximum diameter of abdominal wall defect after resection of abdominal wall tumor was 10.4±5.6 cm. The course of disease was 1–341 months, and the average was 32.4 months. Operative time, postoperative hospitalization time, perioperative complications, tumor recurrence in situ, incidence of postoperative chronic pain, and hernia were recorded.ResultsAll 62 operations were completed successfully. The operative time was 73.2±31.4 minutes, and the mean postoperative hospitalization time was 9.6 days (range, 2–20 days). In total, 54 patients were followed up postoperatively for a median 6.7 years (range, 0.9–9.0 years). Partial splitting of incisions occurred in 2 patients, fat liquefaction of incisions occurred in 3 patients, and chronic pain occurred in 4 patients. No tumor in situ recurrence, hernia, or other complications were found in any cases in the follow-up. Tumor metastasis occurred in 9 patients with 6 of these patients dying of tumour progression.ConclusionsWith simple operations, short procedure time, few complications, low tumor recurrence rate, and low incidence of postoperative chronic pain, application of DCST in the repair of large abdominal wall defects is effective after resection of abdominal wall tumor.

Experience of Component Separation Technique with Open Posterior and Endoscopic Assisted Laproscopic Approach in the Management of Large Midline Ventral Hernias

Background: A novel technique of posterior component separation using transversus abdominis release has been propagated to recreate the midline (Linea alba) in patients with large midline incisional hernias and provides a large space for placement of an underlay mesh. Another recent technique popularized by minimal access surgeons is the endoscopically assisted anterior Component Separation Technique with laparoscopic intra-abdominal composite mesh repair. Method: In our study, we did open Component separation by the posterior approach for the first fifteen patients and Endoscopic assisted component separation with laparoscopic meshplasty for the next fifteen patients. A minimum component separation index from the data of the first fifteen patients was calculated using pre-operative CECT scans validating the requirement of component separation index the endoscopic group of patients. All the repairs were reinforced using a prolene or composite mesh as a standard practice. Result: The wound complications were more with the open technique while the endoscopic procedure was associated with lesser blood loss and faster post-operative recovery. Improved functional and cosmetic outcomes were observed in both groups. Conclusion: The component separation done by either a posterior open or endoscopic technique results in good functional and cosmetic outcomes for the patients with no reported recurrences.

Evaluating the Impact of Technique and Mesh Type in Complicated Ventral Hernia Repair: A Prospective Randomized Multicenter Controlled Trial

To our knowledge, there is an absence of prospective randomized multicenter controlled trials evaluating both the impact of technique and mesh type on outcomes in complicated ventral hernia repair. A prospective randomized multicenter controlled trial of 120 patients at 3 sites was conducted in which patients were randomized to either overlay (anterior component separation) or underlay mesh placement (posterior component separation) and mesh type (human acellular dermis [HADM] vs porcine acellular dermis [PADM]). Key inclusion criteria included hernia size (>200 cm2), BMI < 40 kg/m2, hemoglobin A1C < 7%, tobacco free > 6 weeks and primary fascial closure. Primary outcome was hernia recurrence at 1 year, determined by independent examiner/imaging. Secondary outcomes included complications and patient satisfaction (short form [SF]-36v2). Standardized investigator training included a porcine model followed by a proctored first case by the lead investigator. There were no significant differences in demographics between the 4 groups (age 60 ±12 years, BMI 32 ± 5 kg/m2, 51% female). The overall 1-year recurrence rate was 10.8%. There was no significant difference in recurrence rate by location of mesh placement (overlay 9.8%, underlay 11.9%) or mesh type (HADM 10.3%, PADM 11.3%). Overlay patients had a significantly lower surgical site infection rate (1.6% vs 11.9% p= 0.03), reported better physical functioning (p= 0.001) and role limitation scores (p= 0.04) in the early postoperative period, and achieved the highest physical functioning score during the 12-month period (p < 0.03). Recurrence rates were not affected by either anatomic location or type of mesh used. To our knowledge, this represents the first prospective randomized multicenter controlled trial that demonstrates similar clinical outcomes using HADM vs PADM (not inferiority, contrary to previously published literature), with several advantages identified using the overlay technique.

Open Underlay Mesh Reinforced Large Incisional Hernia Repair—Prospective Observational Hospital Based Study

Introduction: Incisional hernias frequently complicate abdominal surgeries with a varied incidence as reported to be 2% - 20%. The risk factors of development of incisional hernias include immunocompromised state, diabetes mellitus, smoking, obesity, wound infection at the index surgery, emergency surgery. Materials and Methods: The study design was prospective and included 62 patients with incisional hernias. The patients were evaluated preoperatively on OPD basis with history, clinical examination, baseline investigation, ultrasound abdomen and computed tomogram. Results: The mean age was 48.9 years with male:female ratio of 1:1.4. Mean BMI was 30.1 kg/m2. Out of 62 patients in the study 61.2% had concomitant hypertension and were on treatment for the same. 30.6% were clinically hypothyroid, 38.7% were diabetic and 54.8% were smokers. There were multiple factors present in patients in the current study which were observed to be possible to have risked the patients to incisional hernias after an abdominal surgery. 21 patients had defect size ranging from 5 to 10 cm and 41 patients were bearing a hernia of the defect size of 10 cm or more. The mean operative time was 221.7 minutes. Conclusion: Incisional hernias are a part of surgical practice that would probably glue to it to the end of time. A progression from primitive suture repair with recurrence rates of over 65% to modern day mesh reinforced repairs with recurrences aimed at 0% is always welcome. But still then the placement of mesh in different positions or layers of abdominal wall yields different results.

Laparoscopic umbilical herniorrhaphy: a novel technique of hernia neck closure and outcomes in the first 19 cases

Background: Laparoscopicrepair of umbilical hernias are still in its infancy and we present a newapproach to an old problem. Methods: Laparoscopicrepair of umbilical hernias were performed on 19 patients in which the hernianeck was addressed by suturing it closed with a non-absorbable suture and thenapplying an underlay mesh. Data was obtained from operative reports and thesurgeon’s electronic medical records (EMRs). All surgeries were performed by asingle surgeon in a rural hospital in northern Saskatchewan. Results: The resultsshowed no hernia recurrences over a two year follow up.88 percent of patientswere male with BMIs in the range of 22.6–45.3. Six patients had more than 1hernia and the average operative time was 84.75 minutes. Conclusions: Laparoscopicumbilical herniorrhaphy with intra corporeal neck closure is a viable form ofhernia repair. None of the patients presented with umbilical wound infectionsdue to the lack of an incision at the umbilicus. There were also good cosmeticresults due to the reapproximation of the subcutaneous tissue resulting in theformation of a new umbilicus without the obvious scar and deformation oftenassociated with an open repair. A randomised trial is now required as well alonger follow up to determine the efficacy of this technique. The outcomes inthe first 19 patients show a novel technique for umbilical herniorrhaphy whichin the era of laparoscopic surgery we hope will add to the surgicalarmamentarium.

Lateral Abdominal Wall Reconstruction.

Lateral abdominal wall defects, while rare, present a more challenging problem than commonly encountered ventral defects due to the complexity of the anatomy, physiologic forces, and impact of muscle denervation. The lateral abdominal wall encompasses a large surface area ranging from the costal margin superiorly to the iliac crest inferiorly and from the linea semilunaris anteriorly to the paraspinous musculature posteriorly. The ratio of muscle to fascia/aponeurosis is much higher, which makes repair through muscle tissue versus fascia less secure. Furthermore, these defects are subject to asymmetric forces caused by the independent contraction of anterior and posterior muscle units, which lead to unbalanced strain and hernia progression. These features necessitate the use of wide underlay mesh load bearing repairs supported by the static pillars of the abdominal wall. Management can be further complicated when defects extend beyond the defined boundaries, requiring surgical repair to be adapted based on the border structures involved. Primary fascial coaptation may not be as easily accomplished, and therefore careful planning is important to ensure stable coverage of exposed mesh.

Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space.

There has been confusion in the anatomical recognition when performing inguinal hernia operations in Japan. From now on, a paradigm shift from the concept of two-dimensional layer structure to the three-dimensional space recognition is necessary to promote an understanding of anatomy. Along with the formation of the abdominal wall, the extraperitoneal space is formed by the transversalis fascia and preperitoneal space. The transversalis fascia is a somatic vascular fascia originating from an arteriovenous fascia. It is a dense areolar tissue layer at the outermost of the extraperitoneal space that runs under the diaphragm and widely lines the body wall muscle. The umbilical funiculus is taken into the abdominal wall and transformed into the preperitoneal space that is a local three-dimensional cavity enveloping preperitoneal fasciae composed of the renal fascia, vesicohypogastric fascia, and testiculoeferential fascia. The Retzius' space is an artificial cavity formed at the boundary between the transversalis fascia and preperitoneal space. In the underlay mesh repair, the mesh expands in the range spanning across the Retzius' space and preperitoneal space.

The Impact of Body Mass Index on Abdominal Wall Reconstruction Outcomes: A Comparative Study

BACKGROUND Obesity and higher body mass index may be associated with higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall reconstruction. The authors hypothesized that higher body mass indexes result in higher rates of postoperative wound healing complications but similar rates of hernia recurrence in abdominal wall reconstruction patients. METHODS The authors included 511 consecutive patients who underwent abdominal wall reconstruction with underlay mesh. Patients were divided into three groups on the basis of preoperative body mass index: less than 30 kg/m (nonobese), 30 to 34.9 kg/m (class I obesity), and 35 kg/m or greater (class II/III obesity). The authors compared postoperative outcomes among these groups. RESULTS Class I and class II/III obesity patients had higher surgical-site occurrence rates than nonobese patients (26.4 percent versus 14.9 percent, p = 0.006; and 36.8 percent versus 14.9 percent, p < 0.001, respectively) and higher overall complication rates (37.9 percent versus 24.7 percent, p = 0.007; and 43.4 percent versus 24.7 percent, p < 0.001, respectively). Similarly, obese patients had significantly higher skin dehiscence (19.3 percent versus 7.2 percent, p < 0.001; and 26.5 percent versus 7.2 percent, p < 0.001, respectively) and fat necrosis rates (10.0 percent versus 2.1 percent, p = 0.001; and 11.8 percent versus 2.1 percent, p < 0.001, respectively) than nonobese patients. Obesity class II/III patients had higher infection and seroma rates than nonobese patients (9.6 percent versus 4.3 percent, p = 0.041; and 8.1 percent versus 2.1 percent, p = 0.006, respectively). However, class I and class II/III obesity patients experienced hernia recurrence rates (11.4 percent versus 7.7 percent, p = 0.204; and 10.3 percent versus 7.7 percent, p = 0.381, respectively) and freedom from hernia recurrence (overall log-rank, p = 0.41) similar to those of nonobese patients. CONCLUSION Hernia recurrence rates do not appear to be affected by obesity on long-term follow-up in abdominal wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.

Force Comparison of Commercially Available Transfascial Suture Passers.

Transfascial suture passers (TSPs) are a commonly used surgical tool available in a wide array of tip configurations. We assessed the insertion force of various TSPs in an ex vivo porcine model. Uniform sections of porcine abdominal wall were secured to a 3D-printed platform. Nine TSPs were passed through the abdominal wall both without and with prolene suture under the following scenarios: abdominal wall only and abdominal wall plus underlay ePTFE or composite ePTFE/polypropylene mesh. Insertion forces were recorded in Newton (N). When passed without suture through the abdominal wall, smaller diameter TSPs required less insertional force (1.50 ± 0.17 N vs 9.68 ± 1.50 N [ P = 0.00072]). Through composite mesh, the solid tipped TSPs required less force than hollow tipped ones (3.87 ± 0.25 N vs 7.88 ± 0.20 N [ P = 0.00026]). Overall, smaller diameter TSPs required less force than the larger TSPs when passed through ePTFE empty (Gore 2.95 ± 0.83 N vs Carter-Thomason 16.07 ± 2.10 N [ P = .0005]) or with suture (Gore 8.37 ± 2.59 N vs Carter-Thomason 19.12 ± 1.10 N [ P = .003]). Diameter plays the greatest role in the force required for TSP penetration. However, when passed through underlay mesh or while holding suture, distal tip shape, the mechanism of suture holding, and shaft diameter all contribute to the forces necessary for penetration. These factors should be considered when choosing a TSP for intraoperative use.

Primary fascial closure with biologic mesh reinforcement results in lesser complication and recurrence rates than bridged biologic mesh repair for abdominal wall reconstruction: A propensity score analysis

Previous studies suggest that bridged mesh repair for abdominal wall reconstruction may result in worse outcomes than mesh-reinforced, primary fascial closure, particularly when acellular dermal matrix is used. We compared our outcomes of bridged versus reinforced repair using ADM in abdominal wall reconstruction procedures. This retrospective study included 535 consecutive patients at our cancer center who underwent abdominal wall reconstruction either for an incisional hernia or for abdominal wall defects left after excision of malignancies involving the abdominal wall with underlay mesh. A total of 484 (90%) patients underwent mesh-reinforced abdominal wall reconstruction and 51 (10%) underwent bridged repair abdominal wall reconstruction. Acellular dermal matrix was used, respectively, in 98% of bridged and 96% of reinforced repairs. We compared outcomes between these 2 groups using propensity score analysis for risk-adjustment in multivariate analysis and for 1-to-1 matching. Bridged repairs had a greater hernia recurrence rate (33.3% vs 6.2%, P<.001), a greater overall complication rate (59% vs 30%, P=.001), and worse freedom from hernia recurrence (log-rank P<.001) than reinforced repairs. Bridged repairs also had a greater rate of wound dehiscence (26% vs 14%, P=.034) and mesh exposure (10% vs 1%, P=.003) than mesh-reinforced abdominal wall reconstruction. When the treatment method was adjusted for propensity score in the propensity-score-matched pairs (n=100), we found that the rates of hernia recurrence (32% vs 6%, P=.002), overall complications (32% vs 6%, P=.002), and freedom from hernia recurrence (68% vs 32%, P=.001) rates were worse after bridged repair. We did not observe differences in wound healing and mesh complications between the 2 groups. In our population of primarily cancer patients at MD Anderson Cancer Center bridged repair for abdominal wall reconstruction is associated with worse outcomes than mesh-reinforced abdominal wall reconstruction. Particularly when employing acellular dermal matrix, reinforced repairs should be used for abdominal wall reconstruction whenever possible.

Assessment of the incidence of chronic pain and discomfort after primary inguinal hernia repair

BackgroundChronic pain and discomfort is a notable complication after inguinal hernia repair. This study assesses the incidence and degree of chronic pain and discomfort after primary inguinal hernia repair performed in our hospital and aims to clarify its relationship to the type of mesh placement. Materials and methodsA retrospective analysis was conducted of 334 patients (378 lesions) who underwent primary inguinal hernia using the Lichtenstein (onlay mesh), Ultrapro Plug (UPP; onlay plus plug mesh), modified Kugel Patch (onlay and underlay mesh), or laparoscopic transabdominal preperitoneal (TAPP; underlay mesh) procedure. Postoperative pain was assessed using a numerical rating scale at postoperative 2-3 wk, 3 mo, and 6 mo. Postoperative discomfort was assessed 6 mo afterward. ResultsQuestionnaire responses were received for 378 lesions (100%) after 2-3 wk, 229 (60.6%) after 3 mo, and 249 (65.9%) after 6 mo. The majority of chronic pain experienced was mild, and no patient suffered from severe pain. The level of pain tended to be less for the TAPP procedure than for other methods. Discomfort at rest was significantly less for TAPP versus Ultrapro Plug (P < 0.01), and discomfort with movement was significantly less for TAPP versus modified Kugel (P < 0.05). ConclusionsOnlay mesh appears to be a risk factor in chronic pain and discomfort. The lower level of chronic pain and discomfort with underlay mesh placement is considered to result from the reduced risk of nerve damage in this procedure than in the onlay mesh placement procedure.

A simplified laparoscopic approach to ventral hernia repair: a new "finned" mesh configuration with defect closure.

Despite the proven benefits of laparoscopic abdominal hernia repair (LAHR), only 25% of elective ventral hernia repairs are currently performed using this method. This surprising trend may be due to the current limitations of LAHR including lack of defect closure, high seroma rates, and longer OR times. To address these challenges, a new method was developed that uses an innovative "finned" mesh configuration to combine defect closure via open dissection and laparoscopic underlay mesh placement. A new "finned" mesh is sutured within the defect edges using a traditional open method and then approached laparoscopically for final fixation onto the peritoneal surface of the abdominal wall. The "fin" provides a perpendicular plane for suturing to avoid unintentional contact with any underlying viscera, centers the mesh symmetrically around the closed defect, and prevents mesh migration without stay sutures. A retrospective review was performed on 108 consecutive patients that had a ventral, incisional, or umbilical hernia repaired using the "finned" mesh between 2007 and 2013. The mean follow-up was 40.83months. Average operating time was 64.84min (range 25-144min) with an average length of stay of 0.80days (range 0-10days). There were two intraoperative complications (1.85%): one small bowel injury and one unexplained incidence of tachycardia. Major post-operative complications included two recurrences (1.85%) and one small bowel obstruction (0.96%). Fourteen minor post-operative complications were observed (12.96%), with the most common being post-operative ileus (n=4) and urinary retention (n=3). There were zero incidents of seroma, wound infection, or mesh infection in this study. This innovative laparoscopic method incentivizes surgeons to embrace the technique and its universally accepted advantages by mitigating the most challenging aspects of LAHR. Promising results indicate a potential new standard of care for ventral hernia repair.