Non-crosslinked porcine-derived acellular dermal matrix for the management of complex ventral abdominal wall hernias: a report of 45 cases

Purpose

Ventral abdominal wall hernias are common and repair is frequently associated with complications and recurrence. Although non-crosslinked intact porcine-derived acellular dermal matrix (PADM) has been used successfully in the repair of complex ventral hernias, there is currently no consensus regarding the type of mesh and surgical techniques to use in these patients. This report provides added support for PADM use in complex ventral hernias.

Methods

In a consecutive series of adult patients (2008–2011), complex ventral abdominal wall hernias (primary and incisional) were repaired with PADM by a single surgeon. Patient comorbidities, repair procedures, and postoperative recovery, recurrence, and complications were noted.

Results

Forty-four patients (mean age, 57.5 years) underwent 45 single-stage ventral abdominal wall hernia repairs (3 primary; 42 incisional). Previously placed synthetic mesh was removed in 17 cases. In 40 cases, primary fascial closure was achieved; in 5 cases, PADM was used as a bridge. Vacuum-assisted closure (VAC) was used for 38/45 cases: 19 closed incisions, 16 cases using the “French fry” technique, and 3 cases with open incisions. Mean hospital stay was 8.2 days (range, 3–32) and mean follow-up was 17 months (range, 1–48). There were 4 (8.9 %) hernia recurrences, 3 requiring additional repair and 1 requiring PADM explantation. There were 3 (6.7 %) skin dehiscences, 4 (8.9 %) deep wound infections requiring drainage, and 5 (11.1 %) seromas (4 self-limited, 1 requiring drainage).

Conclusions

Non-crosslinked intact PADM yielded favorable early outcomes when used to repair complex ventral abdominal wall hernias in high-risk patients.     

The peritoneal flap hernioplasty for repair of large ventral and incisional hernias

Background

Mesh repair of large ventral or incisional hernias is problematic when primary fascial closure cannot be achieved, as this leaves mesh exposed, bridging the gap. We describe a modified retromuscular sublay repair which overcomes this problem and report a retrospective review of cases to assess outcome.

Methods

Mesh is positioned between transposed flaps of preserved hernial sac and rectus sheath. Patients undergoing this repair by one author (BT) from 1 January 2004 to 31 December 2010 were identified, and clinical outcome was assessed by a combination of case-note review, outpatient consultation and telephone interview.

Results

Twenty-one ventral and incisional hernias were treated by this method. Eighteen were incisional (13 midline, three transverse and two oblique incisions), and three were primary paraumbilical hernias. Defect sizes ranged from 25 to 500 cm² and mesh sizes from 300 to 900 cm². Patients were reviewed at 6 weeks, 6 months and at a median of 37 months post-operatively. Three cases of superficial skin edge necrosis, two superficial wound infections and two sizeable seromas developed, but all had resolved within 6 months. One patient developed abdominal wall necrosis requiring mesh removal and eventual abdominal wall reconstruction without mesh, resulting in late recurrence. All other cases achieved excellent long-term outcomes with a high degree of patient satisfaction.

Conclusion

This is a useful method for repairing large ventral and incisional hernias when primary fascial closure is not achievable, combining a sublay mesh repair with autologous tissue transposition across the fascial gap.     

Onlay ventral hernia repairs using porcine non-cross-linked dermal biologic mesh

Introduction

Ventral hernias are common and repair with mesh has been shown to reduce recurrence. However, synthetic mesh is associated with a risk of infection. Biologic mesh is an alternative that may be less susceptible to infection. Typically, the sublay position is preferred for mesh placement but this technique takes longer and has not been shown to have a lower recurrence rate than an onlay mesh. The aim of this study was to evaluate the outcome of complex ventral hernia repair using a porcine non-cross-linked biologic mesh onlay.

Methods

A retrospective chart review was performed of all patients that had a ventral hernia repair with biologic mesh from January 2009 to March 2012. The operative procedure in all patients was an open repair with primary fascial closure (if possible) with or without external oblique component separation and porcine biologic mesh onlay.

Results

There were 22 patients that had a ventral hernia repair, 19 primary and 3 recurrent. The majority were men, had hernia grade 3 or 4, and developed the hernia after an esophagectomy or gastrectomy for cancer. All but one had primary closure with a porcine biologic mesh onlay. One patient was bridged for loss of domain. A bilateral external oblique component separation was added in 16 patients (73 %). The median hospital stay was 7 days. There were two superficial wound infections, one with exposed mesh, but no patient required mesh removal. A seroma requiring intervention developed in 6 patients (27 %) and resolved with pig-tail drainage. At a median follow-up of 7 months, there has been no hernia recurrence apart from the patient that was bridged.

Conclusions

Porcine non-cross-linked biologic mesh overlay has excellent short-term results in patients at increased risk for mesh infection. No patient required mesh removal, and there have been no recurrent hernias in patients with primary fascial closure. Biologic bridging is not effective for long-term abdominal wall reconstruction.     

Wound dehiscence: outcome comparison for sutured and mesh reconstructed patients

Purpose

Treatment guidelines for abdominal wound dehiscence (WD) are lacking. The primary aim of the study was to compare suture to mesh repair in WD patients concerning incisional hernia incidence. Secondary aims were to compare recurrent WD, morbidity, mortality and long-term abdominal wall complaints.

Methods

A retrospective chart review of 46 consecutive patients operated for WD between January 2010 and August 2012 was conducted. Physical examination and a questionnaire enquiry were performed in January 2013.

Results

Six patients were treated by vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) before definitive closure. Three patients died early resulting in 23 patients closed by suture and 20 by mesh repair. Five sutured, but no mesh repair patients had recurrent WD (p = 0.051) with a mortality of 60 %. Finally, 18 sutured and 21 mesh repair patients were eligible for follow-up. The incidence of incisional hernia was higher for the sutured patients (53 vs. 5 %, p = 0.002), while mesh repair patients had a higher short-term morbidity rate (76 vs. 28 %, p = 0.004). Abdominal wall complaints were rare in both groups.

Conclusions

Suture of WD was afflicted with a high incidence of recurrent WD and incisional hernia formation. Mesh repair overcomes these problems at the cost of more wound complications. VAWCM seems to be an alternative for treating contaminated patients until definitive closure is possible. Long-term abdominal wall complaints are uncommon after WD treatment.     

Trans-fascial closure in laparoscopic ventral hernia repair

Background

Laparoscopic incisional hernia repair has become widely accepted in the management of incisional hernias. There has been recent interest in combining fascial closure along with mesh placement to improve outcomes. We report our experience with this technique.

Methods

Cases were evaluated retrospectively from 2012 to 2015. There were no exclusions. Cases were included which involved laparoscopic ventral hernia repair with fascial closure and mesh placement. Fascial closure was performed using non-absorbable sutures passed with a suture passage device percutaneously. A 5-cm overlap was performed using intra-peritoneal mesh. Fixation was performed using absorbable tacks in a double crown technique.

Results

One hundred and twelve cases were included. The mean age was 57 years old (range 33–81 years). Fifty-nine were females and 53 were males. The median post-operative stay for the non-fascial closure group was 0 days (range 0–12 days). The median post-operative stay for the fascial closure group was 0 days (range 0–12 days). All cases were followed up clinically at 6 weeks. In the non-fascial closure group, five patients developed a seroma (12 %). One patient developed a wound infection (3 %). Six patients presented with a recurrence over the study period (15 %). In the fascial closure group, four patients had a seroma, which was managed conservatively (5 %). One patient developed a wound infection (1 %). Five patients developed a recurrence over the study period (7 %).

Conclusion

We have shown comparable rates for seroma and recurrence to other series. Laparoscopic incisional hernia repair with defect closure is feasible and reduces seroma rate and recurrence.

     

Prophylactic Mesh Reinforcement Reduces Stomal Site Incisional Hernia after Ileostomy Closure

Background

Stomal site incisional hernia is a common complication following ileostomy closure. The effectiveness of prophylactic mesh placement at the time of stomal closure is unknown because of fear of mesh infection and subsequent wound complications. The present study investigated whether prophylactic mesh placement reduces the rate of incisional hernia after ileostomy closure without increasing wound complications. The study was based on retrospective review of consecutive ileostomy closures undertaken at a tertiary referral center between January 2007 and December 2011. Hernias were identified through clinical examination and computed tomography.

Results

Eighty-three cases of ileostomy closure were reviewed; 47 patients received mesh reinforcement, and 36 underwent non-mesh closure (controls). In total, 16 (19.3 %) patients developed incisional hernia, 13 (36.1 %) of which occurred in the control group; 3 (6.4 %), in the mesh group [odds ratio (OR): 8.29; 95 % confidence interval (CI) 2.14–32.08; p = 0.001]. Incisional hernia repair was performed in 3 (23 %) patients in the control group; no hernias in the mesh group required surgery. There was no significant difference in wound infection rates between mesh (2 patients, 4.3 %) and control (1 patient, 2.8 %) groups. No mesh infection was found. Multivariate analysis demonstrated that malignancy (OR: 21.93, 95 % CI 1.58–303.95; p = 0.021) and diabetes (OR: 20.98, 95 % CI 3.23–136.31; p = 0.001) independently predicted incisional herniation, while mesh reinforcement prevented hernia development (OR: 0.06, 95 % CI 0.01–0.36; p = 0.002).

Conclusions

Mesh placement significantly reduced the incidence of incisional hernia following ileostomy closure, but without increasing complication rates. This technique should be strongly considered in patients at high risk of hernia development.     

One-Year Follow-up After Open Abdomen Therapy With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction

Background

Open abdomen (OA) therapy frequently results in a giant planned ventral hernia. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) enables delayed primary fascial closure in most patients, even after prolonged OA treatment. Our aim was to study the incidence of hernia and abdominal wall discomfort 1 year after abdominal closure.

Methods

A prospective multicenter cohort study of 111 patients undergoing OA/VAWCM was performed during 2006–2009. Surviving patients underwent clinical examination, computed tomography (CT), and chart review at 1 year. Incisional and parastomal hernias and abdominal wall symptoms were noted.

Results

The median age for the 70 surviving patients was 68 years, 77 % of whom were male. Indications for OA were visceral pathology (n = 40), vascular pathology (n = 22), or trauma (n = 8). Median length of OA therapy was 14 days. Among 64 survivors who had delayed primary fascial closure, 23 (36 %) had a clinically detectable hernia and another 19 (30 %) had hernias that were detected on CT (n = 18) or at laparotomy (n = 1). Symptomatic hernias were found in 14 (22 %), 7 of them underwent repair. The median hernia widths in symptomatic and asymptomatic patients were 7.3 and 4.8 cm, respectively (p = 0.031) with median areas of 81.0 and 42.9 cm², respectively (p = 0.025). Of 31 patients with a stoma, 18 (58 %) had a parastomal hernia. Parastomal hernia (odds ratio 8.9; 95 % confidence interval 1.2–68.8) was the only independent factor associated with an incisional hernia.

Conclusions

Incisional hernia incidence 1 year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic, unlike the giant planned ventral hernias of the past.     

Surgical treatment for giant incisional hernia: a qualitative systematic review

Introduction

Repair for giant incisional hernias is a challenge due to unacceptable high morbidity and recurrence rates. Several surgical techniques are available, but all are poorly documented. This systematic review was undertaken to evaluate the existing literature on repair for giant incisional hernia.

Methods

Literature was identified through a systematic search on PubMed, EMBASE, and CINAHL. We only included studies with clearly defined surgical techniques and defect size of at least 15 cm. The heterogeneity of the studies precluded a meta-analysis. The analysis was based on the premises of a systematic review of the literature.

Results

We identified 14 studies (1,198 patients) including one randomised trial. Studies were mainly small and retrospective and highly heterogenic regarding design, outcome, inclusion, and exclusion criteria. The overall morbidity rate was median 32 % with a wide range between studies of 4–100 %. The mortality ranged from 0 to 5 % (median 0 %) and recurrence rate ranged from 0 to 53 % (median 5 %). Study follow-up ranged from 15 to 97 months (median 36 months). Mesh repair should always be used for patients undergoing repair for a giant hernia, and the sublay position may have advantages over onlay positioning. To avoid tension, it may be advisable to use a mesh in combination with a component separation technique. Inlay positioning of the mesh and repair without a mesh should be avoided.

Conclusions

Evidence to optimise repair for giant hernias is weak due to the heterogeneity and the poor quality of studies. However, sublay positioning of the mesh perhaps in combination with a component separation technique may be advantageous compared with other surgical techniques for giant hernia repair. Giant hernia repair is a challenging surgical procedure and severely lack evidence-based research from high-quality, large-scaled randomised studies.     

Incisional Hernia in Recipients of Adult to Adult Living Donor Liver Transplantation

Background

After receiving a living donor liver transplant (LDLT), an incisional hernia is a potentially serious complication that can affect the patient’s quality of life. In the present study we evaluated surgical hernia repair after LDLT.

Materials and methods

Medical records of patients who underwent surgery to repair an incisional hernia after LDLT in Turgut Ozal Medical Center between October 2006 and January 2010 were evaluated in this retrospective study. A reverse-T incision was made for liver transplantation. The hernias were repaired with onlay polypropylene mesh. Age, gender, post-transplant relaparatomy, the type, the result of surgery for the incisional hernia, and risk factors for developing incisional hernia were evaluated.

Results

An incisional hernia developed in 44 of 173 (25.4 %) patients after LDLT. Incisional hernia repair was performed in 14 of 173 patients (8.1 %) who underwent LDLT from October 2006 to January 2010. Relaparatomy was associated with incisional hernia (p = 0.0002). The mean age at the time of the incisional hernia repair was 51 years, and 79 % of the patients were men. The median follow-up period was 19.2 (13–36) months after the hernia repair. Three patients with intestinal incarceration underwent emergency surgery to repair the hernia. Partial small bowel resection was required in one patient. Postoperative complications included seroma formation in one patient and wound infection in another. There was no recurrence of hernia during the follow-up period.

Conclusions

The incidence of incisional hernia after LDLT was 25.4 % in this study. Relaparatomy increases the probability of developing incisional hernia in recipients of LDLT. According to the results of the study, repair of an incisional hernia with onlay mesh is a suitable option.     

Closure versus non-closure of hernia defect during laparoscopic ventral hernia repair with mesh

Purpose

Laparoscopic ventral hernia repair with mesh versus laparoscopic ventral hernia defect closure with mesh reinforcement. The primary end-point was recurrence.

Methods

Retrospective review of patients who underwent laparoscopic ventral hernia repair for small- and medium-sized hernias between July 2000 and September 2011. These patients were divided: (1) repair with mesh alone (non-closure group) and (2) those with hernia defect closure and mesh reinforcement (closure group). The closure group was further divided by technique: percutaneous versus intracorporeal closure of the defect.

Results

128 patients were studied: 93 patients (72.66 %) in the non-closure group and 35 patients (27.34 %) in the closure group. Follow-up was available in 105 patients (82.03 %) at a mean of 797.2 days (range 7–3,286 days). In the non-closure group there were 14 patients (15.05 %) with postoperative complications and 8 patients (22.86 %) in the closure group, four of which were seromas. Fourteen patients (19.18 %) developed recurrent hernias in the non-closure group with an average time to presentation of 23.17 months (range 5.3–75.3). Two patients (6.25 %) developed recurrent hernias in the percutaneous group with an average time to presentation of 12.95 months (range 9.57–16.33). There have been no recurrences in patients whose defect was closed intracorporeally.

Conclusion

Although our study demonstrated a difference in recurrence rates of 19.18 % in the non-closure group versus 6.25 % in the closure group, the difference did not reach statistical significance. A larger series with longer follow-up may demonstrate clinical significance.     

Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair!

Background

Today, the laparoscopic approach is a standard procedure for the repair of incisional hernias. However, the direct contact of visceral organs with mesh material is a major issue.

Patients and methods

This prospective observational study presents the data of 344 patients treated for incisional and parastomal hernias with a new mesh made of polyvinylidene fluoride (PVDF; Dynamesh IPOM^®) between May 2004 and January 2008 with a minimum follow-up of 6 months. The median follow-up of 297 patients after incisional hernias totaled 24 months and 20 months for 47 patients with parastomal hernias. Incisional hernias were repaired using an IPOM technique. For parastomal hernias, a recently described sandwich technique was used with two meshes implanted in an intraperitoneal onlay position.

Results

The recurrence rate for incisional hernias was 2/297 = 0.6% and 1/47 = 2% for parastomal hernias. Three patients developed a secondary infection after surgical revision or puncture of a seroma. One patient had a bowel fistula through the mesh, with an abscess in the hernia sac. In all cases, the infection healed and the mesh could be preserved. No long-term mesh-related complications have been observed.

Conclusion

The laparoscopic repair of incisional and parastomal hernias with meshes made of PVDF (Dynamesh IPOM^®) revealed low recurrence and, overall, low complication rates. Especially in cases of infection, the material proved to be resistant without clinical signs of persistent bacterial contamination. Mesh-related complications did not occur during the follow-up.     

Sutureless onlay hernia repair: a review of 97 patients

Background

Repair of large ventral/incisional (V/I) hernias is a common problem. Outside of recurrence, other factors such as wound complications and mesh infection can create significant morbidity. Chevrel described the premuscular repair and later modified it by using glue over the midline closure. We previously described our onlay technique using fibrin glue alone in a small case series. The aim of this study is to review the largest case series of sutureless onlay V/I hernia repair whereby mesh is fixated with fibrin glue alone for complex ventral hernias, and how the technique has evolved.

Methods

All patients who underwent onlay V/I hernia repair over a 3-year period were reviewed. Patient demographics, operative details, complications, and follow-up were reviewed.

Results

In total, 97 patients were included. 54.6 % were female, with a mean age of 57.3 years. Mean BMI was 32.2. 23(23.7 %) patients had diabetes. 90 (92.8 %) of the operations were for incisional hernias, 3 (3.1 %) primary ventral hernias, 2 (2.1 %) flank hernias, and 2 (2 %) complex abdominal wall reconstruction. 88 (90.7 %) of the cases were performed on an elective basis. 77 (77.3 %) cases were classified as clean, 21 (21.6 %) clean-contaminated, and 1 (1.0 %) contaminated. The mean defect size was 150 cm². Mean follow-up was 386 days, and maximum was 3.1 years. There were 21 (21.6 %) seromas, 4 (4.1 %) wound infections, 7 (7.4 %) had skin necrosis, and 9 (9.3 %) required re-operation due to a complication. At 3 years, there have been no recurrences or mesh explants.

Conclusions

The sutureless onlay V/I hernia repair with fibrin glue fixation has proven to be durable with a comparable complication profile to other techniques. The most common sequela, seroma, is easily managed in the outpatient setting. This sutureless technique is an effective option for onlay hernia repair that may provide several advantages over traditional suture techniques.

     

Interposition of the hernia sac as a protective layer in repair of giant incisional hernia with polypropylene mesh

Background and purpose

Repair of giant incisional hernia is still associated with high postoperative morbidity and recurrence rates. We evaluated the effectiveness of placing the hernia sac between the viscera and the polypropylene mesh in the repair.

Methods

The subjects of this study were patients with an incisional hernia at least 15 cm in diameter, diagnosed between June 2004 and October 2010 and treated with on-lay polypropylene mesh at least 25 cm in length. We operated using a simplified method of placing the hernia sac between the viscera and the mesh, and fixing the mesh with interrupted trans-fascial U sutures. We evaluated the patient demographics and postoperative complications retrospectively.

Results

A total of 25 patients (mean age 57.1 ± 10 years) were included. The mean length of hospital stay was 1.8 ± 1.2 days. Seroma developed in four patients (16 %), but only two with cystic seroma required excision of the cyst wall with preservation of the mesh. Twenty-two patients (88 %) were followed up for a mean period of 42.6 ± 23 months. There was no incidence of chronic pain, hospitalization for intestinal obstruction, or enterocutaneous fistulization. There was only one recurrence (4.55 %).

Conclusion

The hernia sac can be interposed in all patients undergoing giant incisional hernia repair if direct contact between the polypropylene mesh and intestine is unavoidable.     

Isokinetic strength of the trunk flexor muscles after surgical repair for incisional hernia

Purpose

The repair of incisional hernias can be accomplished by open or laparoscopic techniques. The Biodex^® dynamometer measures muscle strength during isokinetic movement. The objectives of this study are to compare the strength of the trunk flexors between patients who underwent repair for incisional hernia and a control group, and to compare trunk flexion after two kinds of operative techniques for incisional hernias with and without approximation of the rectus abdominis muscles.

Methods

The trunk flexion of 30 patients after different operative techniques for midline incisional hernias and of 12 healthy subjects was studied with the Biodex^® isokinetic dynamometer.

Results

The mean torque/weight (N m/kg) for trunk flexion was significantly higher in the control group compared to the patient group after incisional hernia repair. A significantly higher peak torque/weight [coefficient 24.45, 95% confidence interval (CI) ?0.05; 48.94, P = 0.05] was found in the two-layered suture technique without mesh compared to the laparoscopic technique after adjusting for gender.

Conclusions

The isokinetic strength of the trunk flexor muscles is reduced after an operation for incisional hernia. There is some evidence that a two-layered suture repair with approximation of the rectus abdominis muscles results in higher isokinetic strength of the trunk flexor muscles compared to the laparoscopic technique.     

Short- and mid-term outcome after laparoscopic repair of large incisional hernia

Purpose

To compare the outcome after laparoscopic incisional and ventral herniorrhaphy (LIVH) for fascial defect larger or equal than 15 cm in width with the outcome after LIVH in patients with hernia defect smaller than 15 cm.

Methods

From 2003 through 2010, 350 patients were submitted to LIVH. In 70 cases, hernia defect was ≥15 cm in width and in 280 was <15 cm. Incisional hernias were often recurrent, double or multiorificial. In the group of larger hernias, the rate of obesity, recurrent hernia and multiorificial hernia was 27.1, 24.2 and 12.8 %, respectively, and in the group of smaller hernias 27.3, 16.1 and 2.8 %, respectively. Patients were interviewed using McGill pain score test to measure postoperative quality of life (QoL) in the mid-term.

Results

LIVH for hernia ≥15 cm required longer surgical time (p = 0.034) and postoperative hospital stay (p = 0.0001). Besides, there were higher rate of postoperative prolonged ileus (p = 0.035) and polmonitis (p = 0.001). Overall recurrence rate was 2.6, 8.6 % for larger and 1.1 % for smaller incisional hernias, p = 0.045. Mc Gill pain test revealed no significant difference in the two groups of patients in postoperative QoL within 36 months.

Conclusions

Laparoscopic approach seems safe and effective even to repair large incisional hernia, the rate of recurrence was higher, but acceptable, if compared to smaller hernias. To the best of our knowledge, this is the largest reported series of incisional hernias ≥15 cm managed by laparoscopy.     

Closure of midline contaminated and recurrent incisional hernias with components separation technique reinforced with plication of the rectus muscles

Purpose

Midline incisional hernia reconstruction by defect closure and reinforcement with either prosthetic or biologic materials has shown to significantly decrease recurrence rates even for complex cases. The purpose of this study is to evaluate outcomes regarding large incisional hernia reconstruction with components separation technique using rectus muscle plication as a reinforcement method.

Methods

Thirteen patients having large midline incisional hernias and either history of abdominal wall contamination or recurrence in the presence of mesh were treated between January 2007 and December 2011 with closure using components separation technique reinforced by rectus muscle plication.

Results

Average hernia square was 222 cm², and mean follow-up was 24 months. Complications occurred in 6 patients with a mean time to resolution of 59 days. One recurrence was present.

Conclusions

When use of mesh or biologic materials is not desired, rectus muscle plication is a feasible tool as a reinforcement method after large hernia closure with components separation.     

Evaluation of port site hernias,chronic pain and recurrence rates after laparoscopic ventral hernia repair: a monocentric long-term study

Objective

The aim of this study was to evaluate hernia appearance at the trocar site after laparoscopic treatment of primary or incisional ventral hernias using an intraperitoneal prosthetic mesh. Chronic pain at the trocar site and primary hernia recurrence were also evaluated.

Patients and methods

Two-hundred and twenty-six consecutive patients who underwent a standardized laparoscopic hernia repair for primary or incisional ventral hernia at our centre between January 2000 and December 2008 were included. All patients had clinical and radiological examinations. Primary end points were port site hernia and the occurrence of chronic trocar site pain. Secondary end point was primary hernia recurrence.

Results

Seventy-eight patients were excluded: 6 declined to participate, 48 were unreachable, and 24 did not meet the inclusion criteria (nine underwent a single site laparoscopic approach, ten died of unrelated disease, three were unable to visit the hospital and two had relocated). After exclusion, 148 remained in our study. Mean follow-up was 49 ± 12.6 months. Mean age at the time of surgery was 60 years (range, 28–83) In total, 504 port sites were clinically and radiologically evaluated, and only one (0.02%) had secondary herniation. Three patients (2.0%) had a recurrent hernia, and 14 (9.5%) had developed chronic pain at time of assessment. Nine patients (6.1%) were re-operated for the recurrent hernia before the follow-up evaluation. The overall recurrence rate is, therefore, 8.1%. Only two minor complications and no major complications occurred after surgery. No mortality was observed.

Conclusion

Laparoscopic repair for primary or incisional ventral hernias is a safe surgical approach, with low rates of hernia recurrence and a low morbidity rate. When fascial closure is maintained for 10 mm port sites, the incidence of port site hernias is very low. Five millimetre ports do not require closure.

     

Infected large pore meshes may be salvaged by topical negative pressure therapy

Purpose

To evaluate the efficacy of negative pressure therapy for superficial and deep mesh infections after ventral and incisional hernia repair by a prospective monocentric observational study.

Methods

During a 6-year period, 724 consecutive open ventral and incisional hernia repairs were performed. Pre- and intraoperative data as well as postoperative complications were prospectively recorded. In case of wound infection, negative pressure therapy (NPT) was our primary treatment.

Results

Sixty-three patients (8.7 %) were treated using negative pressure therapy after primary ventral and incisional hernia repair. Infectious complications needing NPT occurred in 54 patients in the retromuscular group (54/523; 10.3 %), none when laparoscopically treated and in 9 patients (9/143; 6.3 %) treated by an open intraperitoneal mesh technique. Considering outcome, all meshes were completely salvaged in the retromuscular mesh group after a median of 5 dressing changes (range, 2–9), while in the intraperitoneal mesh, group 3 meshes needed complete (n = 2) or partial (n = 1) excision. Mean duration to complete wound closure was 44 days (range, 26–63 days).

Conclusion

NPT is a useful adjunct for salvage of deep infected meshes, particularly when large pore monofilament mesh is used.     

Intraperitoneal Mesh Implantation for Fascial Dehiscence and Open Abdomen

Background

Postoperative fascial dehiscence and open abdomen are severe postoperative complications and are associated with surgical site infections, fistula, and hernia formation at long-term follow-up. This study was designed to investigate whether intraperitoneal implantation of a composite prosthetic mesh is feasible and safe.

Methods

A total of 114 patients with postoperative fascial dehiscence and open abdomen who had undergone surgery between 2001 and 2009 were analyzed retrospectively. Contaminated (wound class 3) or dirty wounds (wound class 4) were present in all patients. A polypropylene-based composite mesh was implanted intraperitoneally in 51 patients, and in 63 patients the abdominal wall was closed without mesh implantation. The primary endpoint was incidence of incisional hernia, and the incidence of enterocutaneous fistula was a secondary endpoint.

Results

The incidence of enterocutaneous fistulas after wound closure post-fascial dehiscence (13% vs. 6% without and with mesh, respectively) or post-open abdomen (22% vs. 28% without and with mesh, respectively) was not significantly different. The incidence of incisional hernia was significantly lower with mesh implantation compared with no-mesh implantation in both contaminated (4% vs. 28%; p?=?0.025) and dirty abdominal cavities (5% vs. 34%; p?=?0.01).

Conclusions

Intra-abdominal contamination is not a contraindication for intra-abdominal mesh implantation. The incidence of enterocutaneous fistula is not elevated despite the presence of contamination. The rate of incisional hernias is significantly reduced after intraperitoneal mesh implantation for postoperative fascial dehiscence or open abdomen.     

Medical talc increases the incidence of seroma formation following onlay repair of major abdominal wall hernias

Purpose

Seroma is a well established complication of the repair of major abdominal wall hernias, occasionally requiring aspiration and reoperation. Medical talc seromadesis (MTS) has been described in the literature. The aim of this study was to determine the effect of MTS on seroma formation after onlay repair of incisional hernia.

Methods

A retrospective review of a prospective database was conducted for 5 months from April 2011, when 21 consecutive patients received MTS. Outcomes were compared with a published and validated series from the same unit.

Results

There were no differences in basic demographics and co-morbidities between the two groups. The mean BMI was 34 for the MTS group. The incidence of recurrent incisional hernia prior to surgery was greater in MTS (9/21 vs. 36/116, p = 0.39). The mean area of fascial defect measured intra-operatively and mesh used to cover the incisional hernia defect was 170 and 309 cm² for the MTS group. The mean operating time was 152 min and a mean of 10 g of medical talc was used for seromadesis. The seroma rate increased from 11/116 (9.5 %) to 16/21 (76 %) (p = 0.001) as did the rate of superficial wound infection 10/116 (8.6 %) to 9/21 (43 %) (p = 0.03) in the MTS group. There was no difference in the length of in-hospital stay between the two groups.

Conclusions

The application of medical talc increased the rate of seroma formation and superficial wound infection in patients undergoing open ‘onlay’ repair of major abdominal wall hernia.