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Background: To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation is often performed. In patients with an extreme diameter hernia, anterior component separation and posterior component separation may be combined. The aim of this study was to assess the additional medialization after simultaneous anterior component separation and posterior component separation., Methods: Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Medialization was measured at 3 reference points., Results: Anterior component separation provided most medialization for the anterior rectus sheath, posterior component separation provided most medialization for the posterior rectus sheath. After combined component separation techniques total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional posterior component separation after anterior component separation provided 15% to 16%, and additional anterior component separation after posterior component separation provided 32% to 38% of the total medialization after combined component separation techniques. For the posterior rectus sheath, additional posterior component separation after anterior component separation provided 50% to 59%, and additional anterior component separation after posterior component separation provided 11% to 17% of the total medialization after combined component separation techniques. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization., Conclusion: Anterior component separation provided most medialization of the anterior rectus sheath and posterior component separation provided most medialization of the posterior rectus sheath. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The primary objective was to assess the perioperative efficacy of the preoperative use of progressive pneumoperitoneum or Botulinum Toxin A injections in ventral hernia repair., Methods: Embase, Medline Ovid, Web of Science, Cochrane Central, and Google Scholar were systematically searched. Studies in English reporting on fascial closure, indications, complications or postoperative outcomes in adult patients that had undergone progressive pneumoperitoneum, Botulinum Toxin A injections, or both before ventral hernia repair were included. Study quality was assessed with the Oxford Levels of Evidence guidelines and the Methodological Index for Non-Randomized Studies criteria. A pooled fascial closure rate and recurrence rate were calculated with random effects models., Results: Twenty studies were included from the 905 identified, comprising the use progressive pneumoperitoneum (n = 11), Botulinum Toxin A (n = 6), and both techniques (n = 3). The overall fascial closure rate was 0.94 (95% confidence interval 0.89-0.98). Indications for the use of progressive pneumoperitoneum or Botulinum Toxin A were based on objective (eg, computed tomography measurements) or subjective measures (eg, foreseen surgical problems). In contrast to the use of Botulinum Toxin A, reported complications with the use of progressive pneumoperitoneum were ample and sometimes severe. The cumulative reported recurrence rate was 0.03 (95% confidence interval 0.01-0.06)., Conclusion: Preoperative progressive pneumoperitoneum and Botulinum Toxin A can facilitate fascial closure without causing significant numbers of adverse events. Botulinum Toxin A qualifies for low-threshold use, yet progressive pneumoperitoneum should be used cautiously owing to a larger number of complications. Definitive recommendations cannot be made as the quality of included studies is low, bias is present, and comparative information is scarce. Registration number Information about the design and conduct of this systematic review has been registered on PROSPERO, registration number CRD42020181679., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Task-specific checklists and global rating scales are both recommended assessment tools to provide constructive feedback on surgical performance. This study evaluated the most effective feedback tool by comparing the effects of the Observational Clinical Human Reliability Analysis (OCHRA) and the Objective Structured Assessment of Technical Skills (OSATS) on surgical performance in relation to the visual-spatial ability of the learners., Methods: In a randomized controlled trial, medical students were allocated to either the OCHRA (n = 25) or OSATS (n = 25) feedback group. Visual-spatial ability was measured by a Mental Rotation Test. Participants performed an open inguinal hernia repair procedure on a simulation model twice. Feedback was provided after the first procedure. Improvement in performance was evaluated blindly using a global rating scale (performance score) and hand-motion analysis (time and path length)., Results: Mean improvement in performance score was not significantly different between the OCHRA and OSATS feedback groups (P = .100). However, mean improvement in time (371.0 ± 223.4 vs 274.6 ± 341.6; P = .027) and path length (53.5 ± 42.4 vs 34.7 ± 39.0; P = .046) was significantly greater in the OCHRA feedback group. When stratified by mental rotation test scores, the greater improvement in time (P = .032) and path length (P = .053) was observed only among individuals with low visual-spatial abilities., Conclusion: A task-specific (OCHRA) feedback is more effective in improving surgical skills in terms of time and path length in novices compared to a global rating scale (OSATS). The effects of a task-specific feedback are present mostly in individuals with lower visual-spatial abilities., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Large incisional hernias require medialization of the rectus abdominis muscles to facilitate tension-free closure. Medialization may be achieved by Rives-Stoppa, anterior component separation, or posterior component separation. This study aims to compare medialization achieved by these techniques in postmortem human specimens., Methods: First, the Rives-Stoppa procedure was performed. Subsequently, anterior and posterior component separation were performed on one side in each specimen, with each specimen functioning as its own control. Medialization was measured at three levels of the linea alba with three 1-kg weights. Both medialization obtained in addition to initial medialization after opening the linea alba and total medialization were measured. Results are presented as median and interquartile range., Results: A total of 13 postmortem human specimens were included (Rives-Stoppa n = 13, component separation n = 10). Additional medialization after Rives-Stoppa was 1.2 cm (IQR: 0.3-2.2) for the anterior rectus sheath and 2.2 cm (IQR: 1.6-3.0) for the posterior rectus sheath (total medialization: 3.9 and 4.5 cm). For the anterior rectus sheath, additional medialization was 2.6 cm (IQR: 1.2-3.6) after anterior component separation and 1.9 cm (IQR: 0.4-3.4) after posterior component separation (P = .125, total medialization: 6.5 and 5.7 cm). For the posterior rectus sheath, additional medialization was 3.0 cm (IQR: 2.2-3.7) after anterior component separation and 5.2 cm (IQR: 4.2-5.9) after posterior component separation (P < .001, total medialization: 5.8 and 9.4 cm)., Conclusion: Posterior component separation yielded significantly more medialization of the posterior rectus sheath compared with Rives-Stoppa and anterior component separation. Anterior component separation may provide marginally more medialization of the anterior rectus sheath., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Primary ventral hernia is a common condition. Surgical repair is associated with complications, but no clear predictive risk factors have been identified. The European Hernia Society classification offers a structured framework to describe hernias and to analyze postoperative complications. Given this structured nature, the European Hernia Society classification might prove useful for preoperative patient or treatment classification. The objective of this study was to investigate the European Hernia Society classification as a predictor for complications within 30 days after primary ventral hernia surgery., Methods: A registry-based, prospective cohort study was performed, including all patients undergoing primary ventral hernia surgery between September 1, 2011 and February 29, 2016. Univariate analyses and multivariable logistic regression analysis were performed to identify risk factors for postoperative complications., Results: A total of 2,374 patients were included, of whom 105 (4.4%) patients had ≥1 complications, either a wound, surgical, or medical complication. Factors associated with complications in univariate analyses (P<.10) and clinically relevant factors were included into the multivariable analyses. In the multivariable analyses, age, body mass index, and the duration of the operation were independent risk factors. The diameter of the hernia was not an independent risk factor., Conclusion: Primary ventral hernia repair is associated with a 4.4% rate of complications. No correlation was found between the European Hernia Society classification and postoperative complications. Age, body mass index, and duration of the operation were correlated with postoperative complications. Therefore, age and body mass index should be used in the preoperative risk assessment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Bile duct injury remains a dilemma in laparoscopic cholecystectomy, with an incidence still higher than in conventional cholecystectomy. The Critical View of Safety technique is used as one of the important operating technique to reduce bile duct injury incidence. The objective of this study was to determine current practices in laparoscopic cholecystectomy and the use of the Critical View of Safety technique among surgeons and residents in surgical training., Methods: We conducted an electronic survey among all affiliated members of the Association of Surgeons of the Netherlands containing questions regarding the current practice of laparoscopic cholecystectomy, essential steps of the Critical View of Safety technique, reasons for conversion to open cholecystectomy, and the use of other safety techniques., Results: The response rate was 37% (766/2,055). In the study, 610 completed surveys were analyzed. Of the respondents, 410 (67.2%) were surgeons and 200 (32.8%) were residents in surgical training. Furthermore, 98.2% of the respondents indicated incorporating the Critical View of Safety technique into current practice. However, only 72% of respondents performed the essential steps of the Critical View of Safety technique frequently. Subsequently, half of respondents were able to identify the corresponding steps of the Critical View of Safety technique, and only 16.9% were able to distinguish these adequately from possible harmful steps. Furthermore, 74.9% selected ≥1 possible harmful steps as part of this technique. Residents significantly performed and selected the essential steps of the Critical View of Safety technique more often than surgeons. Intraoperative cholangiography, intraoperative ultrasound, and fluorescence cholangiography are seldom used. Bail-out techniques such as subtotal cholecystectomy, fundus first dissection, and leaving the gallbladder in situ are familiar to the majority of respondents., Conclusion: Responses indicate that practically all Dutch surgeons and residents claim to use the Critical View of Safety technique. The majority of surgeons and residents are unable to discern correctly the essential steps of the Critical View of Safety technique from actions not part of the technique and even potentially harmful. Residents' current knowledge regarding the Critical View of Safety technique is superior to those of surgeons., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Laparoscopic adhesiolysis as a therapy for chronic pain is still controversial, and long-term effects are not known; therefore, our aim was to evaluate long-term effects of laparoscopic adhesiolysis for the treatment of chronic abdominal pain believed to be related to intraperitoneal adhesions., Methods: A total of 100 patients with abdominal pain attributed to adhesions were randomized to laparoscopic adhesiolysis or a placebo group with laparoscopy alone. Pain relief was assessed after 12-year follow-up., Results: A total of 73% of patients fulfilled the long-term follow-up. Compared to the placebo group (n = 31), patients in the adhesiolysis group (n = 42) were significantly less often pain-free (8 vs 13, P = .033, relative risk [RR] = 1.3) and to have a greater intake of analgesics (26 vs 16, P = .379, RR = 1.2, 95% confidence interval 0.8-1.8). Moreover, the adhesiolysis group sought medical consultations more frequently (14 vs 6, P = .186, RR = 1.33, 95% confidence interval 0.9-1.9), and had an increased rate of additional operation (8 vs 1, P = .042, RR = 1.67, 95% confidence interval 1.208-2.318). Both groups had improved pain and quality-of-life scores., Conclusion: This is the first, long-term, placebo-controlled trial regarding the use of laparoscopic adhesiolysis for treating chronic abdominal pain. Laparoscopic adhesiolysis was less beneficial than laparoscopy alone in the long term. Secondly, there appeared to be a powerful, long-lasting placebo effect of laparoscopy. Because adhesiolysis is associated with an increased risk of operative complications, avoiding this treatment may result in less morbidity and health care costs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The objective was to evaluate the incidence and treatment of incisional hernia after kidney transplantation and to identify potential risk factors., Methods: A retrospective cohort study was performed. All kidney transplant recipients between 2002 and 2012 were included. Two groups were identified: patients with and without incisional hernia. An analysis of risk factors for the development of incisional hernia was performed., Results: A total of 1,564 kidney recipients were included. Fifty patients (3.2%) developed incisional hernia. On univariate analysis, female sex (54 vs 35%), body mass index (BMI) >30 kg/m(2) (38 vs 17%), concurrent abdominal wall hernia (30 vs 16%), multiple explorations of the ipsilateral iliac fossa (38 vs 19%), left iliac fossa implantation (36 vs 24%), history of smoking (72 vs 57%), and duration of the kidney transplantation procedure (210 vs 188 minutes) were associated with the development of incisional hernia (P < .05 each). In multivariate analyses, female sex (hazard ratio [HR] 2.6), history of smoking (HR 2.2), obesity (BMI >30; HR 2.9), multiple explorations of the ipsilateral iliac fossa (HR 2.0), duration of operation (HR 1.007), and concurrent abdominal wall hernia (HR 2.3) were independent risk factors. Twenty-six of 50 patients (52%) underwent operative repair, of whom 9 (35%) required emergency repair., Conclusion: The incidence of incisional hernia after kidney transplantation with a median follow-up of 59 months is 3.2%. Obesity (BMI >30), female sex, concurrent abdominal wall hernias, history of smoking, duration of surgery, and multiple explorations were independent risk factors for the development of incisional hernia after kidney transplantation. Attempts at preventing incisional hernias based on these risk factors should be explored., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Prospective data on risk factors and the incidence of inguinal hernia are sparse, especially in an elderly population. The aim of this study was to determine the incidence of and risk factors for inguinal hernia., Methods: We analyzed data from the Rotterdam Study, a prospective cohort study that observed the general population aged ≥45 years of Ommoord, a district in Rotterdam, from baseline (1990) over a period of >20 years. Diagnoses of inguinal hernia were obtained from hospital discharge records and records from general practitioners. Multivariate regression analysis was performed to determine risk factors for inguinal hernia development., Results: Among 5,780 men, with a total of 50,802 person-years, who did not have a hernia at baseline, 416 cases of inguinal hernia (7.2%) occurred. The 20-year cumulative incidence was 14%. Age-adjusted hazard ratio (HR) for inguinal hernia for men relative to women was 12.4 (95% CI, 9.5-16.3; P < .001). On multivariate analysis, the risk of inguinal hernia increased with advancing age (HR per 1-year increase in age, 1.03; 95% CI, 1.02-1.04; P < .001). Participants with a body mass index (BMI) of 25-30 kg/m2 had an HR of 0.72 (95% CI, 0.58-0.89; P = .003) compared with a BMI of <25; a BMI of >30 had an associated HR of 0.63 (95% CI, 0.42-0.94; P = .025)., Conclusion: Inguinal hernia is common in the middle-aged and elderly male population and its incidence increases with advancing age. Overweight or obese patients have a lesser risk of developing an inguinal hernia., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Incisional hernia (IH) is among the most common postoperative complications after abdominal surgery. Operative treatment (OT) using mesh is the treatment of choice. A strategy of watchful waiting (WW) might be a considered in some patients. This retrospective study compares the outcomes of WW and OT., Methods: All patients presenting with IH in an academic surgery department between January 2004 and December 2009 were analyzed according to whether they were treated by WW or OT. Crossovers between both groups were also analyzed. Patient characteristics, information about the initial abdominal operative procedure, symptoms at presentation, and characteristics of the hernia were collected retrospectively. In case of OT, postoperative complications were analyzed., Result: In total, 255 patients were included; 151 (59%) in the OT group and 104 (41%) in WW group. The median follow-up was 68 months (interquartile range [IQR], 52-93). The reasons for WW were the absence of symptoms in 34 patients (33%), comorbidities in 24 (23%), and obesity in 23 (22%). During follow-up, 34 patients (33%) crossed over from WW to OT. Eight of the crossovers (24%) were emergency repairs owing to incarceration at a median of 1 month (IQR, 1-5) after the start of WW. The incidence of unexpected intraoperative intestinal perforation was greater in the crossover group (13%) compared with the OT group (2%; P = .002). Postoperative fistulas were seen in 7% of patients who crossed over from WW to OT versus 0% in primary OT (P = .002). Postoperatively, 3 patients died, 2 of whom were treated operatively after belonging initially to the WW group., Conclusion: WW for IH leads to high crossover rates with significantly greater incidence of intraoperative perforations, fistulas, and mortality, than in the OT group, particularly in patients who require emergency repair of IH owing to incarceration., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Incisional hernia (IH) can be attributed to multiple factors. The presence of a parastomal hernia has shown to be a risk factor for IH after midline laparotomy. Our hypothesis is that this increased risk of IH may be caused by changes in biomechanical forces, such as midline shift to the contralateral side of the colostomy owing to decreased restraining forces at the site of the colostomy, and left abdominal rectus muscle (ARM) atrophy owing to intercostal nerve damage., Methods: Patients were selected if they underwent end-colostomy via open operation between 2004 and 2011. Patients were eligible if computed tomography (CT) had been performed postoperatively. If available, preoperative CTs were collected for case-control analyses. Midline shift was measured using V-scope application in the I-space, a CAVE-like virtual reality system. For the ARM atrophy hypothesis, measurements of ARM were performed at the level of colostomy, and 3 and 8 cm cranial and caudal of the colostomy., Results: Postoperative CT were available for 77 patients; of these patients, 30 also had a preoperative CT. Median follow-up was 19 months. A mean shift to the right side was identified after preoperative and postoperative comparison; from -1.3 ± 4.6 to 2.1 ± 9.3 (P = .043). Furthermore, during rectus muscle measurements, a thinner left ARM was observed below the level of colostomy., Discussion: Creation of a colostomy alters the abdominal wall. Atrophy of the left ARM was seen caudal to the level of the colostomy, and a midline shift to the right side was evident on CT. These changes may explain the increased rate of IH after colostomy creation., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: Incisional hernia (IH) is the most frequent complication after abdominal operation, with an incidence of 11-20% and up to 35% in risk groups. Known risk groups for IH are abdominal aortic aneurysm and obesity. Our hypothesis is that parastomal hernia (PH) might also represent a risk factor for developing IH. Identifying risk factors can help determine the need for preventive measures such as primary mesh augmentation., Methods: In a multicenter cross-sectional study, all patients who were operated between 2002 and 2010 by means of a Hartmann procedure or abdominoperineal resection were invited for a follow-up visit to our outpatient clinic. Primary outcome measures were the prevalence of IH and PH. All possible risk factors for IH were scored. A physical examination was performed and, when available, computed tomography was scored for IH and PH., Results: A total of 150 patients were seen in the outpatient clinic. The median follow-up was 49 months (range, 30-75). IH had a prevalence of 37.1%, and PH had a prevalence of 52.3% during physical examination. On CT the prevalence was even greater, ie, 48.3% and 52.9%. IH and PH were both present in the same patient in 30% of all examined and in 35.6% after CT examination. PH was found to be a risk factor for IH on univariate and multivariate logistic regression analyses of variance, with an odds ratio of 7.2 (95% confidence interval 3.3-15.7). In addition, an emergency operation was found to be a risk factor for IH with an odds ratio of 5.8 in the multivariate analyses., Conclusion: Patients with a PH have a 7 times greater chance of developing an IH compared to patients without PH., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: Patients with both cirrhosis and ascites have a 20% risk of developing umbilical hernia. A retrospective study from our center comparing conservative management of umbilical hernia with elective repair in these patients showed a significant risk of mortality as a result of hernia incarceration in conservatively treated patients. The goal of this study was to assess the safety and efficacy of elective umbilical hernia repair in these patients prospectively., Methods: Patients with liver cirrhosis and ascites presenting with an umbilical hernia were included in this study. For all patients, the expected time to liver transplantation was more than 3 months, and they did not have a patent umbilical vein in the hernia sac. The following data were collected prospectively for all patients: Child-Pugh-Turcotte (CPT) classification, model for end-stage liver disease (MELD) score, kidney failure, cardiovascular comorbidity, operation-related complications, and duration of hospital stay. Mortality rates were registered in hospital records and verified in government records during follow-up. Mortality rates were registered in hospital records and verified in government records during follow-up. On completion of the study, a retrospective survey was performed to search for any patients who met the study inclusion criteria but were left out of the study cohort., Results: In total, 30 patients (25 males) underwent operation at a mean age of 58 years (standard deviation [SD] ± 9 years). Of these 30 patients, 6 were classified as CPT grade A (20%), 19 (63%) as grade B, and 5 (17%) as grade C. The patients' median MELD score was 12 (interquartile range [IQR], 8-16). In 10 (33%) of the 30 patients hernia repair was performed with mesh. The median duration of hospital stay was 3 days (IQR, 2-4). None of the patients were admitted to the intensive care unit. Postoperative complications included pneumonia and decompensation of cirrhosis (1 case each,) resulting in prolonged hospital stay for those 2 patients. After a median follow-up period of 25 months (IQR, 14-34), 2 (7%) of the 30 patients died; neither of the deaths were attributable to the umbilical hernia repair. A total of 2 patients suffered recurrence., Conclusion: Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Open mesh or non-mesh inguinal hernia repair may influence the incidence of chronic postoperative pain differently., Methods: A total of 300 patients scheduled for repair of a primary unilateral inguinal hernia were randomized to non-mesh or mesh repair. The primary outcome measure was clinical outcome including persistent pain and discomfort interfering with daily activity. Long-term results at 3 years of follow-up have been published. Included here are 10-year follow-up results with respect to pain., Results: Of the 300 patients, 87 patients (30%) died and 49 patients (17%) were lost to follow-up. A total of 153 were physically examined in the outpatient clinic after a median long-term follow-up of 129 months (range, 109 to 148 months). None of the patients in the non-mesh or mesh group suffered from persistent pain and discomfort interfering with daily activity., Conclusions: Our 10-year follow-up study provides evidence that mesh repair of inguinal hernia is equal to non-mesh repair with respect to long-term persistent pain and discomfort interfering with daily activity. An important new finding from the patient's perspective is that chronic postoperative pain seems to dissipate over time.