OBJECTIVES AND BACKGROUND: Ventral hernias are a frequent reason for surgical consultation, and its incidence is higher in the obese population. In this article, we analyze the relationship between obesity and abdominal wall pathology and its influence in surgical results. PROCEDURE: A literature search strategy was performed to analyze this relationship. RESULTS: Obesity is not only a risk factor for the appearance of abdominal wall hernias and incisional hernias but also for complications after ventral hernia repair. Obesity also increases the risk of incarceration and recurrence after repair. In these patients, the laparoscopic approach minimizes the risk and comorbidity generated by obesity in abdominal wall surgery obtaining better results. Joint surgery with laparoscopic bariatric surgery seems to be a feasible technique with lower recurrence rates in different studies. Despite these results, conclusive studies are still insufficient to make recommendation concerning hernia repair in patients undergoing bariatric surgery. CONCLUSIONS: There is a strong association between obesity and abdominal wall hernias, and the laparoscopic approach seems to offer better results regarding comorbidity of obesity.

BACKGROUND: Following herniorrhaphy, deep surgical site infections with mesh involvement (dSSI-MI) traditionally necessitate mesh removal, putting patients at risk for hernia recurrence. There is no consensus about managing infected mesh, as salvage strategies are poorly reported. We describe our outcomes following dSSI-MI at two high-volume hernia centers. MATERIALS AND METHODS: A retrospective review of hernia repairs complicated by dSSI-MI with subsequent salvage attempt was undertaken. Outcome measures included duration of antibiotic use, recurrent dSSI-MI, need for mesh excision, postoperative complications, and hernia recurrence. RESULTS: Thirteen patients underwent attempted mesh salvage (female = 8, median age = 64, and median body mass index = 30.6). 62% had an average of 1.5 prior mesh repairs, and 23% had prior surgical site infection. Twelve underwent open ventral or parastomal hernia repairs, while one patient had a prophylactic mesh augmentation. Three cases required concomitant bowel surgery. Eight dSSI-MIs resulted from gastrointestinal tract complications. All patients received antibiotics for median of 17 days. 92% required operative management of dSSI-MI (100% incision and drainage, 66% debridement of soft tissue). Negative-pressure wound therapy (NPWT) was utilized in 92% for an average of 26 days. One patient was successfully managed without an operation. With a median follow-up of 34 months, there were two recurrent hernias, only one requiring repair. CONCLUSIONS: Despite requiring significant postoperative care (reoperations, prolonged antibiotics, and NPWT), mesh salvage without complete explantation is feasible following dSSI-MI, with a low rate of recurrent hernia formation or long-term infections. Salvage attempts were undertaken primarily in patients with retromuscular macroporous polypropylene, suggesting that repair type and mesh choice influence the decision-making for salvage.

BACKGROUND: This paper determines the most important risk factors associated with surgical site occurrence (SSO) and recurrence following open incisional hernia repair using synthetic mesh. METHODS: Retrospective review at a tertiary care hospital of adults who underwent incisional hernia repair using synthetic mesh by a single surgeon (2008–2015). Primary outcomes were SSO and hernia recurrence. Risk factors of body mass index >25, diabetes, active smoking, previous repair, bridged repair, and fascial defect size >10 cm were analyzed via Cox proportional hazard model and stepwise regression for SSO and recurrence. A Kaplan–Meier curve compares hernia recurrence for small versus large hernia groups. RESULTS: The overall recurrence rate was 19%. Only large fascial defect size was significantly associated with an increased risk of recurrence at all levels of analysis. Bridged repair was significantly associated with SSO on all levels of analysis except when paired with large hernia size in Cox multivariate analysis. CONCLUSIONS: Key technical aspects of the hernia repair surgery, specifically a fascial defect over 10 cm in width and performance of a bridged fascial repair pose a greater risk for hernia recurrence and SSO than patient comorbidities, including diabetes, active smoking, previous repair, and obesity. These results further indicate that synthetic mesh can be used safely in the one-stage repairs of incisional hernias in patients with comorbidities, without unacceptably high rates of SSO or hernia recurrence.

OBJECTIVE: The aim of this study is to elucidate the guideline conformity and to analyze the surgical techniques, outcomes, and the use of devices and consumables for the first 100 cases of laparoscopic inguinal hernia (IH) repair performed during an institutional hernia programme (IHP) in a single surgical center. METHODS: This is a retrospective review of the first consecutive 100 cases of laparoscopic IH repair performed during IHP. Patient's demographic, operation techniques, the use of devices and consumables, and outcomes are reviewed. RESULTS: A total of 185 IHs were laparoscopically repaired in 100 male patients with a mean age of 37.86 (range: 24–68) years from May 2015 to April 2019. Common indications for laparoscopic IH repair are bilateral IH (n = 85) and recurrences after the previous open repair (n = 11). A total extraperitoneal repair (TEP) was performed in 96 patients, and transabdominal preperitoneal repair was performed in four patients. The mean operation time was 35.97 (range: 10–90 min). Electrosurgical energy, surgical suction, and laparoscopic scissors were used in seven, four, and six patients, respectively. All the surgeries performed with low-cost standard polypropylene meshes. Surgical takers used in seven patients to anchor the mesh (n = 6) and close the peritoneal defect (n = 1). Conversion to open procedure was required in a single patient. The single hematoma was the only complication encountered. Seven patients developed unilateral recurrences after TEP repair for bilateral IH during the mean follow-up period of 2 years and 3 months. All the patients were discharged within 23 h of the surgery. CONCLUSIONS: This study shows a higher level of guideline conformity of the laparoscopic IH repair with acceptable level of recurrence while using a minimum number of costly devices and consumables.

BACKGROUND: Incisional hernia (IH) is the most frequent complication of laparotomy with an increasing incidence over time. A large amount of them present in complex forms with large defects or even loss of domain. There is still no consensus regarding the optimal surgical approach for this IHs. The posterior component separation with transversus abdominis release (TAR) alone or in combination with augmentation of the abdominal wall became the standard of repair in large IHs (LIH). No clear evidence that TAR alone can recreate the normal volume of the peritoneal cavity is available. We assessed if it is possible to reconstruct normal peritoneal volume (PV) by TAR. MATERIALS AND METHODS: In this retrospective study, data from LIH patients with midline defects equal or larger than 10 cm width, and computed tomography scans available before and 1-week after TAR with complete fascial closure were analyzed. Hernia sac volume (HSV), abdominal cavity volume (ACV), and (PV = HSV + ACV) were evaluated before surgery. Peritoneal index (PI) was calculated as HSV/PV ratio. PV was measured at 7 days post-TAR (PV_TAR). The compliance of the abdominal wall (C_ab) was calculated as the ratio between the difference of the PV before surgery and after TAR and the difference between preoperative intra-abdominal pressure (IAP) and postoperative IAP. RESULTS: 23 consecutive patients with a mean age of 64 years were included in the study. The mean value of the HSV was 3,775 cm³ and of the ACV 8377 cm³. PI varied between 0.22 and 0.4. A statistically insignificant difference was recorded between PV and PV_TAR(P = 0.7). Patients with PI ≥0.3 had the volume of the peritoneal cavity lesser than patients with PI <0.3. The compliance of the abdominal wall was decreased for the patients with defects larger than 15 cm width and PI larger than 0.33. Urine output in the first postoperative day was smaller in the patients with PI larger than 0.3 with a statistically significant (P = 0.0002) difference and was highly correlated with the abdominal perfusion pressure (APP) and PI. CONCLUSIONS: TAR is able to recreate normal PV in LIH patients with PI <0.3. When PI is larger than 0.33, a permissive intraabdominal hypertension develops for 24 h with the reduction of the APP and of the urine output. In this condition, the augmentation of the abdominal wall could be considered as an option by preoperative administration of pneumoperitoneum and/or Botulin toxin.

Surgical mesh infections from ventral hernia repairs are common in obese patients. Definitive management includes the surgical removal of mesh; however, obese patients are often poor surgical candidates with limited therapeutic options. We report the case of a 64-year-old male with an abdominal wall seroma secondary to an infected surgical mesh. This was on a background of multiple abdominal wall reconstructions for previous strangulated ventral hernias. A nonoperative novel approach utilizing bromelain percutaneously in conjunction with antibiotics successfully resolved the infected seroma. The purpose of this case is to detail the potential clinical application of bromelain in surgical site infections involving surgical prosthesis. We illustrate the successful use of bromelain as a nonoperative alternative for abdominal infections or when all other surgical and conservative therapies have been exhausted.

Repair of inguinal hernia is one of the most common procedures in general surgical practice. Amyand's hernia is an unusual condition that entails the presence of the appendix in the hernial sac. In this case, we present a rare combination of Type II Amyand's hernia and sliding hernia that was discovered during elective hernial repair in a male patient. The inflamed appendix was removed, and tension-free Lichtenstein repair was performed. Postoperative recovery was uneventful with no recorded complications or recurrence of hernia. Amyand's hernia is usually diagnosed intraoperatively. The association of a sliding component with Amyand's hernia did not alter the management plan. The use of synthetic mesh in Type II Amyand's hernia is safe and feasible, despite the recommendation to avoid prosthetic repair in this type of hernia.

Endometriosis is a condition in which cells similar to those in the endometrium, of the uterus, grow outside of it. Mostly, it is found around the uterus but rarely may occur in other parts of the body. Endometriosis can affect any organ of the body, but inguinal hernia sac endometriosis is extremely rare. Inguinal hernia sac endometriosis appears as a painful tender swelling in the inguinal region. Here, we report a case of right inguinal hernia sac endometriosis which was diagnosed by surgical excision and biopsy.