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Transversus abdominis muscle release: Technique, indication, and results
Wolfgang Reinpold
October-December 2018, 1(3):79-86
Component separation technique (CST) allows the mobilization of large musculofascial flaps of the abdominal wall and was developed for the treatment of very large, primary and incisional abdominal wall hernias. The classic open anterior CST first published by Albanese and later by Ramirez is associated with high complication rates. According to a recent literature review, CST without mesh should no longer be performed because of high recurrence rates. Classic anterior CST is associated with high rates of surgical-site occurrences and infections and should only be performed as endoscopic- and perforator-sparing anterior CST. The unfavorable results of classic CST resulted in the development of numerous new anterior and posterior CST modifications, several of them were minimally invasive. The posterior CST with transversus abdominis muscle (TAM) release (TAR) published by Novitsky et al. is an extension of the original retrorectus Rives operation and Stoppa procedure. The technique avoids vast skin flaps and allows the closure of large abdominal wall defects and insertion of very large retromuscular alloplastic standard sublay meshes without damaging the vessels and intercostal nerves. The TAR procedure is one of the major advances of abdominal wall surgery of the last decades. Several new promising minimally invasive modifications including robotic-assisted TAR have been published recently. The indications and technique of the TAM (TAR) procedure and its minimally invasive modifications are described.
  27,172 2,451 6
Optimal management of mesh infection: Evidence and treatment options
Michael R Arnold, Angela M Kao, Korene K Gbozah, B Todd Heniford, Vedra A Augenstein
July-September 2018, 1(2):42-49
Mesh reinforcement is generally considered the standard of care in ventral hernia repair. Infection is a common complication following ventral hernia repair. Infection extending to the mesh is a complex problem. Knowledge of current treatment strategies is necessary for surgeons performing abdominal wall reconstruction. A comprehensive literature review was performed of current literature to assess risk factors and treatment options for mesh infection. Modifiable risk factors for mesh infections include active smoking, poorly controlled diabetes mellitus, abdominal skin or wound issues, and obesity. Operative factors that increase the risk of mesh infection include prior hernia repair, enterotomy and contamination of the surgical field. Of the synthetic meshes, lightweight polypropylene has the highest likelihood of salvage. Patients that are current smokers, those with other synthetic mesh types, and those infected with MRSA are rarely salvaged. Following excision of infected mesh, multi-staged abdominal wall reconstruction can be considered. Biologic or biosynthetic mesh is recommended when repairing incisional hernias following excision of infected mesh and likely represent the patient's best chance at a definitive hernia repair. Wound VAC-assisted delayed primary closure should be considered in higher-risk patients. Mesh infection is a complex complication that is commonly encountered by surgeons performing hernia repair. Prevention through patient optimization should be performed whenever appropriate. However, when patients develop a mesh infection, most will require complete mesh excision and recurrent hernia repair.
  19,221 1,568 6
Laparoscopic view of surgical anatomy of the groin
Reinhard Bittner
April-June 2018, 1(1):24-31
BACKGROUND: Deep knowledge of anatomy is essential for the success of any surgical intervention. This is especially true for inguinal hernia repair, due to the complex anatomical structure of the groin. METHODS: Observation and documentation of the pathology of the groin in >15,000 laparoscopic inguinal hernia repairs and careful study of the literature describe the anatomy in cadaver preparation. RESULTS: The large variability of the course of the nerves and the utmost importance of the bilaminar structure of the transversalis fascia for a precise dissection of the pelvic floor as well as for the placement of a large flat mesh are described in detail. CONCLUSION: Competent knowledge of the anatomy of the groin facilitates the operative performance, enables a tissue-protective dissection, and may provide an uncomplicated postoperative course.
  11,058 1,198 -
Inguinal neuroanatomy: Implications for prevention of chronic postinguinal hernia pain
Danielle S Graham, Ian T MacQueen, David C Chen
April-June 2018, 1(1):1-8
Inguinal hernia repairs represent one of the most common general surgery operations worldwide. Advances in the understanding of groin anatomy, operative technique, and prosthetics have improved the efficacy of these repairs with overall low recurrence rates and favorable outcomes. Chronic postherniorrhaphy inguinal pain has arguably become the most important and most frequent complication of inguinal hernia repair, with significant impact on patients' quality of life. Neuropathic inguinodynia may be caused by direct nerve injury, manipulation, entrapment, scarring, and interaction with mesh. Development of chronic postinguinal hernia repair pain is independent of the method of hernia repair as all inguinal hernia repair techniques may potentially cause injury. Understanding the neuroanatomy of the inguinal canal and the potential mechanisms for injury leads to lower rates of nerve injury and chronic pain and helps to guide prevention and treatment of inguinodynia. In this article, the neuroanatomy of the anterior inguinal canal and the prevention of nerve injury are addressed.
  7,678 718 -
Thromboembolic prophylaxis in hernia surgery
Henry Hoffmann, Ralph Fabian Staerkle, Philipp Kirchhoff
July-September 2018, 1(2):37-41
INTRODUCTION: Thromboembolic prophylaxis (TP) is an effective strategy to reduce the risk of thromboembolic events such as deep vein thrombosis and pulmonary embolism. In the absence of patient- and procedure-related risk factors, the risk of thromboembolic events is considerably low among surgical patients. Since hernia repair is thought to be a low-risk procedure, the role of TP in patients undergoing hernia surgery is a matter of debate. METHODS: A systematic search of the literature was conducted in Medline/PubMed and the Cochrane database. Forty-eight relevant publications were identified. RESULTS: Overall, there is a paucity of studies specifically investigating the impact of TP in patients undergoing hernia surgery. Available studies demonstrate that the risk of thromboembolic events with TP in inguinal hernia repair is approximately 0.1%, comparable to other low-risk procedures. Lower rates of thromboembolic events are seen in outpatient surgery. Laparoscopy and implanted mesh in the groin do not increase the risk of thromboembolic events. CONCLUSION: Due to the limited data, no recommendation for or against TP in hernia surgery can be made. Further studies are urgently needed to investigate the effect of TP on the risk of thromboembolic events in patients undergoing hernia repair.
  6,840 462 1
Prevention of seroma formation after laparoscopic inguinoscrotal indirect hernia repair by a new surgical technique: A preliminary report
Junsheng Li, Zhenling Ji, Xiangyu Shao
July-September 2018, 1(2):55-59
BACKGROUND: Seroma formation is a frequent complication of laparoscopic inguinoscrotal hernia, and the most appropriate technique regarding the distal sac management in laparoscopic inguinoscrotal hernia is still debated. The aim of this study is to present a new technique to manage the large distal sac and to avoid the clinical significant seroma formation after laparoscopic inguinoscrotal hernia repair. MATERIALS AND METHODS: One hundred and ninety-five consecutive elective inguinal hernias were performed in our group in 1-year period and 12 of them were inguinoscrotal indirect hernias, defined as the hernia sac descending into the scrotum. In these inguinoscrotal hernia patients, the distal hernia sacs were transected and left in place without complete dissection out of scrotum and reduction. Then, the lower edge of the distal sac was fixed to the posterior abdominal wall cranial and lateral to the internal ring with barbed suture. The patients were prospectively followed with physical examination, and in five of them, ultrasound was performed on the 1st day and 7th day after the operation. The primary postoperative outcome parameter was seroma formation; the secondary parameters included groin pain, surgical complications, and early hernia recurrence. RESULTS: Only one patient developed clinical significant seroma by physical examination during the follow-up period. The patients complained no chronic groin pain, and there were no other surgical complications and early hernia recurrence in these series. CONCLUSION: Seroma formation could be effectively prevented by suspension of the lower edge of the distal sac to the posterior abdominal wall is an easy, reproducible, reliable, and cost-effective method to prevent postoperative clinical significant seroma formation after laparoscopic inguinoscrotal hernia repair. Although the early results were promising, the comparative studies and randomized controlled trials are necessary for further evaluation.
  6,057 425 3
Outside of guidelines: Successful Desarda technique for primary inguinal hernias
Ralph Lorenz
January-March 2019, 2(1):23-24
  5,894 500 2
A single-blind, randomized controlled study to compare Desarda technique with Lichtenstein technique by evaluating short- and long-term outcomes after 3 years of follow-up in primary inguinal hernias
Hemanth Vupputuri, Satish Kumar R, Priya Subramani, Venugopal K
January-March 2019, 2(1):16-22
BACKGROUND: Lichtenstein tension-free repair is associated with postoperative complications and dysfunctions; hence, there is a need to look for a new hernia repair techniques while retaining its advantages. Desarda technique is a physiologic repair and essentially restores physiology of the inguinal canal. This single-blind, randomized controlled study was conducted to compare Desarda with Lichtenstein technique evaluating short- and long-term outcomes after 3 years of follow-up in primary inguinal hernias. MATERIALS AND METHODS: One hundred and twenty-three adult male patients with primary inguinal hernia (both direct and indirect) were randomly allocated intraoperatively to Lichtenstein repair, Mesh (M) Group or Desarda repair, nonmesh (NM) Group. Baseline characteristics were recorded before the surgery. Short- and long-term outcomes and patients responses on patient global impression of change (PGIC) and Prolo scale after surgery were recorded. RESULTS: Sixty-two patients were assigned to NM and 61 to M group. Surgery time was significantly higher for M group (P < 0.001). Postsurgical pain was significantly higher (P < 0.001) in M than NM group whereas complications were comparable. The total mean duration of follow-up for M was 35.2 months while for NM was 35.7 months. The recurrence rate was not significantly different; however, chronic groin pain was significantly higher in M compared to NM (P = 0.05). After surgery, PGIC score was consistently higher in NM group with better functionality in NM group. CONCLUSIONS: After 3 years of follow-up, Lichtenstein technique and Desarda technique results were similar. After considering the pros and cons of both the methods, a tailor-made approach is required while choosing a procedure for hernia repair.
  4,494 499 1
Current state of repair of large hiatal hernia
David I Watson
April-June 2019, 2(2):39-43
Large hiatus hernias are encountered with increasing frequency in aging Western populations. If certain steps are followed, repair can be safely and reliably achieved using laparoscopic approaches. However, surgeons disagree about some key steps, including the use of mesh for repair of the hiatus, lengthening of the esophagus, and the addition of a fundoplication. A narrative review of literature pertinent to laparoscopic repair of large hiatus hernia was undertaken, with priority given to information available from randomized trials. All surgeons agree that the hiatal sac should be fully dissected from the chest to reduce the stomach, and the majority add a fundoplication of some sort. Opinions diverge significantly for the addition of a Collis procedure or the use of mesh. Evidence cited to support these opinions can be prioritized differently by different individuals, and the same evidence is often be cited to support either view. Nevertheless, randomized trials of mesh versus sutured hiatal repair have yielded divergent outcomes, with the more recent studies reporting longer term outcomes failing to support the use of mesh. Surgeons seeking “anatomical perfection” will often add a Collis procedure and are more likely to use mesh. However, the alternative view is that patient satisfaction with the clinical outcome should be prioritized. When this view is taken, a Collis procedure is rarely required. The author concludes that surgeons should aim to keep this operation simple, and an approach which prioritizes careful dissection to protect hiatal structures, followed by sutured repair will deliver a good clinical outcome for most patients.
  4,323 375 1
Surgery for incarcerated inguinal hernia: Outcomes with Lichtenstein versus open preperitoneal approach
Cuihong Jin, Yingmo Shen, Jie Chen, Fuqiang Chen, Min Liu, Fan Wang, Fenglin Zhao
April-June 2019, 2(2):44-49
BACKGROUND AND AIM: Incarcerated inguinal hernia comprises a significant portion of surgical emergencies, and represents about 5%–15% of all operated inguinal hernias. Tension-free repair with mesh placement is the preferred technique for elective surgery due to its low recurrence rate. However, limited information is available on the usage of synthetic mesh in the emergent treatment because of the potentially infected surgical fields, especially in case of concomitant bowel resection. The aims of this study were to evaluate the results of mesh-based emergency hernioplasty and compare the outcomes of incarcerated inguinal hernia repair with synthetic mesh in Lichtenstein or open preperitoneal approach and to identify the risk factors for postoperative complications. METHODS: A total of 151 patients with incarcerated inguinal hernia that underwent surgery between January 2013 and December 2017 were included in this retrospective study. Demographics, surgical details, and outcomes such as surgical-site infection and recurrence were collected. Univariate analysis was employed to identify risk factors for overall complications. RESULTS: A total of 61 patients received Lichtenstein hernial repair, whereas 90 patients received open preperitoneal repair. Overall morbidity occurred in 21 patients. There was no significant difference between the two groups in terms of postoperative complications. Univariate risk factors for overall complications were age >65 years, duration of incarceration ≥8 h, American Society of Anesthesiologists grade ≥III, cardiopathy, bronchial asthma, indirect inguinal hernia, and strangulation. In multivariate analysis, no risk factors were found associating with a higher rate of overall morbidity. CONCLUSION: As for incarcerated inguinal hernia, both Lichtenstein and open preperitoneal approach with mesh are safe and effective.
  4,368 326 1
Antibiotic prophylaxis in laparoendoscopic hernia surgery
Ferdinand Kockerling
April-June 2018, 1(1):9-12
INTRODUCTION: Whether antibiotic prophylaxis can really reduce the rate of surgical site infections (SSIs) or rather tends to increase the risk of antimicrobial resistance development is being increasingly questioned even for elective surgery in a clean surgical field. Since compared with the open technique, the laparoendoscopic technique per se reduces the SSI rate, that possibility must also be considered for laparoendoscopic repair of inguinal and abdominal wall hernias despite these techniques always using a mesh as a foreign body. MATERIALS AND METHODS: A systematic search of the literature was conducted in Medline/PubMed and the Cochrane database. Thirty-two relevant publications were identified. RESULTS: Overall, there is a paucity of studies on antibiotic prophylaxis in laparoendoscopic hernia surgery. Those studies available are not able to demonstrate that the use of antibiotic prophylaxis in laparoendoscopic repair of inguinal and abdominal wall hernias has a definite effect on the SSI rate. Hence, antibiotic prophylaxis can be omitted with for patients with no risk factors. But that does not apply for patients with risk factors, such as obesity, diabetes mellitus, emergency surgery, contaminated surgical field, recurrent hernia, chronic obstructive pulmonary disease, abdominal aortic aneurysm, prior SSI, long operative time, and other factors influencing the SSI rate. CONCLUSION: Further studies are urgently needed on antibiotic prophylaxis in laparoendoscopic hernia surgery in particular in association with risk factors.
  4,029 423 -
Surgery of abdominal wall hernias in Russia with special reference to new technical developments
V Abolmasov Alexey, V Abolmasov Andrey, Bashankaev Badma, AM Tariverdiev
July-September 2018, 1(2):50-54
BACKGROUND: We analyzed historic date to follow up hernia surgery changes in Russia since 2002 till 2018 to find out the technical tendencies and to predict the development in the future. METHODS: Official annual statistic report data, mailing questionaries&#39; of Russian Surgery Society, Russian Surginet community and internet survey, generated by surveymonkey.com were used to obtain information regarding inguinal and ventral hernia therapy in Russia. RESULTS: For the first 12 patients operated on in the new eTEP technique we recorded no surgical site infection and recurrence. All patients were satisfied with the procedure. The median operative time was 98 min (range: 82 – 160 min). Good cosmetics were achieved in all patients. CONCLUSIONS: Unfortunately, the principal method of umbilical and midline hernia repair in Russia is a double layer technique without paying attention to concomitant rectus diastasis. This is one of the main reasons for the high recurrence rate.
  3,808 432 -
Laparoscopic transversus abdominis release for the treatment of complex ventral hernia
Li Binggen, Miao Jinchao, Shi Shange, Qin Changfu
October-December 2018, 1(3):87-93
BACKGROUND: Posterior component separation through transversus abdominis muscle release (TAR) is an increasingly accepted technique worldwide for complex ventral hernia repair. Recently, researchers have attempted to perform the TAR procedure using minimally invasive approaches. In this study, we present our experience of laparoscopic TAR (Lap-TAR). The procedure will be described in detail and its feasibility evaluated. PATIENTS AND METHODS: To learn and be proficient in the procedure through soft cadaver workshop practice, we accumulated the necessary knowledge and minimally invasive surgery skills for the Lap-TAR procedure. We selected an appropriate patient and performed a Lap-TAR operation to treat complex ventral hernia. RESULTS: The Lap-TAR operation was successfully performed in a 73-year-old female patient with a giant lower abdominal incisional hernia, without open conversion. The estimated blood loss was 60 mL and the operative time was 365 min. The postoperative pain was mild, and the visual analog pain scale score was 3 on postoperative day (POD) 2. The patient was discharged on POD 7. All subfascial drains were removed before patient discharge. On an initial follow-up period of 3 months, there was no evidence of wound complication, bulging, or hernia recurrence. CONCLUSIONS: The Lap-TAR operation is technically feasible with a deliberate preparation. It could be an alternative for complex abdominal wall reconstruction with the potential to reduce pain, facilitate recovery, and decrease the length of hospital stay of patients.
  3,888 337 -
Comparison of intraperitoneal ventralex ST patch versus onlay mesh repair in small and medium primer umbilical hernia
Birol Agca, Yalin Iscan
January-March 2019, 2(1):1-6
PURPOSE: Although the size of the hernia plays an active role in the use of the mesh, the counter-view is that the use of the mesh should be preferred regardless of the size of the hernia. In our study, the clinical results of two different mesh types applied under elective conditions to small-and medium-sized umbilical hernia cases were examined. PATIENTS AND METHODS: Between January 2015 and May 2018, intraperitoneal Ventralex ST repair and onlayprolene mesh repair were performed in 88 primary small and medium umbilical hernia cases. Demographic data, duration of surgery, length of hospital stay postoperative complications, and recurrence were recorded. RESULTS: Eighty-eight patients were analyzed including 54 males and 34 females – a mean age of 50.3 years. The duration of the surgery in Ventralex ST group was 35.9 ± 4.1 min. (P < 0.05). Comparing to the visual analog scale (VAS) values of the 1st day, the decrease in VAS values in both groups on the 7th day was statistically significant (P < 0.05). The rates of early and late postoperative complications, such as seroma, hematoma, wound infection, and recurrence, were similar between the procedures. The mean follow-up period was 23 months (with range 7–46 months), and no recurrence was observed in both groups. CONCLUSION: We think that the Ventralex ST mesh performed with open surgical technique under elective conditions for primitive umbilical hernias can be safely used because of its quick applicability and low rates of complication and recurrence.
  3,811 368 -
A case for open inguinal hernia repair
John Morrison
October-December 2018, 1(3):69-73
The open approach to inguinal hernia repair has several distinct advantages in the management of both primary and recurrent groin hernia repairs. A variety of repair techniques are available to suite the patient's condition. Both pure tissue and mesh techniques in a tailored fashion may be employed, rather than the cookie-cutter approach where the mesh is used in the same fashion in every case. Most patients with preexisting comorbidities may have repair carried out under local or regional anesthesia instead of general anesthesia as required by laparoscopy. Studies have demonstrated the efficacy of open preperitoneal mesh placement in the treatment of recurrent inguinal and femoral hernia repair, where hernia recurrence rates, postoperative complications, and long-term patient outcomes are equivalent to laparoscopic repair. The use of robots has yet to demonstrate any advantage over manual repairs either open or laparoscopic, with extended operating time and extreme cost. Return to normal daily activity is advocated in 3–7 days whichever technique is used.
  3,674 397 -
Laparoscopic round ligament preserving repair for groin hernia in women: A critical appraisal
V Abolmasov Alexey, Badma Bashankaev
October-December 2019, 2(4):130-133
BACKGROUND: Our objective was to investigate the clinical characteristics of original laparoscopic round ligament-sparing repair technique for groin hernias in female patients. METHODS: The clinical data of 48 female patients (58 hernias) who underwent laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair using original split mesh technique at Orel Regional Hospital (Russia) between March 2009 and January 2019 were analyzed retrospectively. The aim of the study was to provide an overview about female groin hernias, preferred surgical approach, and the management of round ligament of uterus. RESULTS: There were 58 TAPP repairs in 48 patients. The average follow-up period was 43 months (min. – 3, max. – 122, Mo – 12, and Me – 43). Fifteen femoral hernias were noted in ten patients, of which two femoral hernias were incarcerated. Cysts on the round ligament of the uterus were found in four patients, and most of them underwent laparoscopic resection. Round ligaments of the uterus were preserved in all patients. An average operation time was 56 min (min. – 20, max. – 135, Mo – 40 min, and Me – 50 min). None of the cases was converted to laparotomy. All patients returned to normal activity soon and 1 (1.7%) recurrence was noted during follow-up. CONCLUSION: Laparoscopic inguinal hernia repair is well adopted around the world, but still questions remain which are related to female patients, especially regarding the function and preserving the round ligament. Based on this study, it is possible to preserve the round ligament by using the original laparoscopic TAPP keyhole technique.
  3,592 231 1
Fundamentals of incisional hernia prevention
Samuel A Heathcote, Zachary F Williams, W Borden Hooks, William W Hope
April-June 2018, 1(1):32-36
BACKGROUND: The incidence of incisional hernia following surgery is a major economical and clinical burden for healthcare. METHODS: This report reviews and consolidates pertinent literature related to hernia prevention to give surgeons a solid framework on the current perspectives and emerging topics related to incisional hernia prevention. RESULTS: Pertinent anatomy and fundamentals of laparotomy closures are reviewed. Recommended closures of laparotomy incisions include the use of monofilament, slowly absorbing suture in a running fashion with a 4:1 suture to wound length ratio using a short stitch technique. The use of prophylactic mesh reduces the rate of incisional and parastomal hernias in high-risk patients. CONCLUSION: The current fundamentals of hernia prevention including pertinent anatomy and surgical techniques for appropriate laparotomy closures should be known to surgeons operating on the abdominal wall. The use of prophylactic mesh to reduce incisional and parastomal hernias has shown promise, and further research is needed to evaluate long-term efficacy.
  3,208 359 -
The breakthrough on evaluation and treatment in incisional hernia with loss of domain
Dailei Qin, Shibo Wei, Jiyu Tian, Zhiwei Guo, Xian Li, Yuhao Yan, Hangyu Li
April-June 2019, 2(2):33-38
Part of the patients with incisional hernia (IH) suffered from constipation or even circulatory impairment, which is called large IH with loss of domain (LOD) or giant IH. For now, there is still controversy about the definition and pathomechanism of the LOD; meanwhile, there is no clear criterion for evaluating and treating patients with LOD. A systematic search of the literature was implemented in PubMed and the Cochrane database by using the keywords “IH, abdominal wall function(AWF), LOD” and got 60 publications finally. First, there is still no unified definition for LOD, but we found that it was translated into a situation that abdominal content can hardly be reduced with AWF deficiency in 2018th Chinese Guidelines. Second, we concluded that poor abdominal wall contraction caused by muscular atrophy or fibrillation after large area aponeurosis released shall be important pathomechanism of LOD. Third, we found that there are different methods for evaluating LOD, while the activity evaluation may be most useful. Finally, component separation technique (CST), bridge repair or utotransplantation have been recommended in many publications for variable condition. The definition of LOD is better to be divided into the functional deficiency and the anatomical defect just like Chinese guidelines. The pathomechanism of LOD was actually based on anatomical destruction of abdominal wall contraction system. The activity evaluation may be the most convenient method mentioned in the publications. CST was strongly recommended to be used in giant hernia, the defect of which can be hardly closed. Patients who have IH with LOD are proposed to receive hernioplasty as early as possible because of the impendency to reconstruct the large defect on the abdominal wall as well as restoration of the AWF. Surgeons may select appropriate CST to repair IH according to the length of the defect.
  2,804 378 -
Retrospective single-center experience with the transversus abdominis muscle release procedure in complex abdominal wall reconstruction
Yonggang Huang, Ping Wang, Jing Ye, Guodong Gao, Fangjie Zhang, Hao Wu
July-September 2018, 1(2):60-65
OBJECTIVE: The objective of the study was to investigate the clinical utility of the transversus abdominis muscle release (TAR) procedure in complex abdominal wall reconstruction. MATERIALS AND METHODS: Retrospective study of 32 patients with complex abdominal wall defects admitted to Hangzhou First People's Hospital between January 2016 and December 2017. Clinical materials were collected and analyzed. RESULTS: Among 32 cases of large incisional hernias, there were 19 males (59.4%) and 13 females (40.6%). Mean age was 64.41 ± 12.11 years, body mass index was 30.00 ± 5.97 kg/m2, and mean width of the abdominal defect was 11.34 ± 1.82 cm. Twenty-four cases were midline incisional hernias with one case of planned incisional hernia after severe pancreatitis, and three cases were lateral. Five cases were recurrent incisional hernias. All patients underwent retromuscular mesh repair, with abdominal wall reconstruction using the TAR procedure. The operative time was 151.59 ± 28.64 min, and estimated blood loss was 118.12 ± 83.41 cm3. Length of hospital stay was 13.66 ± 2.72 days. Two cases had a superficial surgical site infection, five had Type II seroma, and one had intestinal obstruction. All postoperative complications resolved with nonsurgical therapy. No mesh infection, fistula, recurrence, or postoperative bulging was reported during follow-up. CONCLUSION: Posterior component separation through TAR is a reliable and effective technique for complex abdominal wall reconstruction. Long-term follow-up is needed to assess potential recurrence.
  2,867 305 -
Peritoneal closure using self-anchoring-barbed absorbable sutures during laparoscopic transabdominal preperitoneal inguinal hernioplasty: How to make it more safe?
Axel Gilbert, Fawaz Abo-Alhassan, Pablo Ortega-Deballon, Nicolas Cheynel, Patrick Rat, Olivier Facy
January-March 2019, 2(1):7-11
CONTEXT: Peritoneal closure with a barbed suture during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a controversial subject due to the risk of postoperative intestinal adhesions and occlusions formed by this type of suture. This risk, however, was only reported in several case reports. The purpose of this study is to determine the incidence of postoperative intestinal obstructions related to the use of barbed suture materials in laparoscopic hernia repair (TAPP). PATIENTS AND METHODS: We included all patients that underwent laparoscopic TAPP inguinal hernia repair between October 2012 and October 2017. All peritoneal closures were accomplished using absorbable barbed sutures. Operative data were collected in a dedicated database and analyzed retrospectively. RESULTS: Only 3 out of the 320 patients included (0.9%) presented with an early postoperative intestinal obstruction and required further surgery. Two of the three patients (0.6%) were found to have intestinal incarceration in the peritoneal defects initially created during the hernia repair. However, the last patient had an intestinal volvulus due to adhesions formed with the barbed suture. None of the patient characteristics collected were significant risk factors for developing postoperative intestinal obstructions. CONCLUSION: In this study, peritoneal closure using barbed suture material did not increase the risk of early postoperative intestinal obstruction, in comparison to other suture materials reported in the literature. The use of barbed absorbable sutures for peritoneal closure during laparoscopic TAPP seems to be safe when sutures are cut short and covered by the peritoneum.
  2,713 311 1
Laparoscopic transabdominal Morgagni hernia repair
Rebekah Macfie, Sean Orenstein, David Tse
July-September 2018, 1(2):66-68
Morgagni hernias are a rare finding in the adult population and represent 1%–3% of all congenital diaphragmatic hernias. Multiple approaches to these rare hernias have been described in the literature. Here, we present a novel technique of laparoscopic transabdominal repair using a combination of the Endo-Close device (Medtronic, Minneapolis, MN, USA) and the Ti-KNOT (LSI Solutions, Victor, NY, USA). In a patient with a large left anterior diaphragmatic defect, we performed transabdominal suturing utilizing the Endo-Close to perform primary closure of the defect, using the Ti-KNOT to secure the pledged sutures along the anterior fascia. Due to the size of the defect (7 cm × 10 cm), this primary repair was buttressed with polyester mesh. In a second patient with a smaller (6 cm × 8 cm) classic right-sided anterior diaphragmatic defect, we similarly performed laparoscopic transabdominal suturing using the Endo-Close to traverse both the anterior and posterior fascia and the Ti-KNOT to secure the sutures to perform a primary repair of the hernia. Both patients presented had an uneventful postoperative course and no indication of recurrence at 4 months. Morgagni hernias present unique technical challenges. In our experience, the combined use of transabdominal suture with laparoscopic knot placement device allowed for completion of both cases laparoscopically with minimal tension on the repairs.
  2,694 252 1
Case series of a novel open plication supported by mesh (PSUM) - technique for symptomatic abdominal rectus diastasis repair with or without concomitant midline hernia: Early results and a review of the literature
Reetta Tuominen, Jaana Vironen, Tiina Jahkola
October-December 2019, 2(4):142-148
BACKGROUND: Abdominal rectus diastasis (ARD), sometimes combined with abdominal wall midline hernia, is a common complaint in women after childbirth. To some individuals, ARD causes functional disability. Convincing data of the long-term results of ARD repair are lacking, especially when ARD is severe, and the optimal technique is undefined. In plastic surgery, the repair is often done with suture alone, but if a concomitant hernia exists, using a mesh is mandatory. This paper reports a novel surgical technique aimed at a reliable and minimally traumatic repair of ARD with or without midline hernia and a review of the literature of ARD repair. PATIENTS AND METHODS: During June 2013–April 2018, 37 consecutive patients with symptomatic ARD with or without concomitant midline hernia were operated on by using a narrow piece of a self-gripping mesh (n = 32) or the tails of the ventral patch (n = 5). The mesh was placed in between the plicated linea alba. The outcome and patient satisfaction in this pilot study were analyzed. RESULTS: A significant subjective improvement in body balance after surgery was reported by 34 patients (92%). During the mean follow-up of 13 months, there was only one partial recurrence of ARD. The complication rate was low, and patient satisfaction was good. CONCLUSION: According to the present study, selected patients with severe lack of muscle control and/or back pain benefit from ARD repair. The minimally traumatic PSUM mesh augmentation seems a promising method for the repair of ARD.
  2,700 240 -
Obesity as a risk factor for complications and recurrences after ventral hernia repair
Elena Pareja Nieto, Carme Balague Ponz, Sonia Fernández Ananin, Eulalia Ballester Vazquez
January-March 2020, 3(1):1-3
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.
  2,510 296 -
Tenogenic differentiation of mesenchymal stem cells improves healing of linea alba incision
Dong Wang, Zhen-Ling Ji, Jing-Min Wang, Yu-Yan Tan
April-June 2018, 1(1):13-18
OBJECTIVE: The aim of this study is to investigate the curative effects of mesenchymal stem cells' (MSCs') tenogenic differentiation on Linea alba incision healing. MATERIALS AND METHODS: Autologous MSCs were isolated from rat bone marrow and cultured and induced by 10 ng/mL of bone morphogenetic protein-12 (BMP-12) for 48 h. Expression of scleraxis (SCX), collagen I, and collagen III was examined at 48 h, 5 days, and 7 days to investigate the tenogenic differentiation. Fifty Sprague-Dawley rats were randomly divided into five groups: tenogenically differentiated (group E) or native mesenchymal stem cells (group D) seeded onto collagen sponge scaffolds or only sponge scaffolds (group C) were transplanted into the linea alba incision; rats that underwent operation without implantation of anything served as the sham group (group B), and rats that did not undergo operation were used as the control group (group A). Histological analysis was performed to explore the curative effects. RESULTS: The expression of SCX increases continually even in the absence of BMP-12 for 5 days (P < 0.01). However, the expression of collagen I and III requires persistent inducing by BMP-12. Abundant numbers of cells are present in the midline incision compared to the native linea alba structure (Group A), and Group B has the most serious inflammation, with obvious inflammatory corpuscles. From the sections stained with Masson's trichrome, the tenogenic differentiation of MSCs treating the Linea alba incision demonstrates a relatively rich and well-aligned collagen fibrous matrix along the transverse (tensile) axis of the incision. CONCLUSIONS: In animal experiments, MSCs' tenogenic differentiation induced by BMP-12 can dramatically enhance linea alba incision healing.
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Comparison of totally extraperitoneal groin hernia repair with and without mesh fixation
Lubov Kupershlyak, Zvi Perry, Boris Kirshtein
October-December 2019, 2(4):134-141
INTRODUCTION: Since the introduction of the laparoscopic technique for tension-free inguinal hernia repair, various mesh fixation techniques have been adopted. The need for mesh fixation during the surgery is still under debate. We conducted our study to compare the outcomes of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair with (MF) and without (NMF) mesh fixation. PATIENTS AND METHODS: One hundred and fifty-seven patients underwent laparoscopic inguinal hernia repair without mesh fixation during 2010–2014. Of these, 113 (71.9%) agreed to participate in our trial, underwent physical examination, and filled out a questionnaire regarding their satisfaction with the surgery outcome. The data collected from medical records and results of the examination and the questionnaire were processed statistically and compared to the results of a previous study, which included patients who underwent TEP with mesh fixation. RESULTS: Mean follow-up was about 3 years in both groups. Duration of procedure and length of hospital stay were shorter in the NMF group. Patients without mesh fixation had less pain and earlier return to work and physical activity. There was no significant difference in recurrence rate between NMF and MF groups (5.6% and 4.6%, respectively). The majority of recurrences in the MF group were among patients in whom a nonsplit mesh was used. Surgery satisfaction, however, was significantly higher in the MF group. CONCLUSION: TEP without mesh fixation results in better surgical and postoperative outcome comparing with mesh fixation. Overall hernia recurrence rate was similar in patients with and without mesh fixation. Regular follow-up of at least 18 months is recommended to define true recurrence rate.
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