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Objective: To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair., Summary Background Data: Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For noncomplex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking., Methods: Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models., Results: Ninety-three studies representing 12,440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% [95% confidence interval (CI): 2.2%-4.2%, n = 11,049] after minimally 12months and 4.1%, (95%CI: 2.9%-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2%-6.4%, n = 4891) and 5.5% (95%CI: 4.4%-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair [odds ratios (OR): 0.27, 95%CI: 0.15-0.51, P < 0.001] and equal recurrence rates compared to intraperitoneal onlay mesh (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, P = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03 -3.14, P = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7%-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8%-2.8%, n = 982), albeit based on non-randomized studies., Conclusions: Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except SSI. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

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: Patients with a re-recurrent hernia may account for up to 20% of all incisional hernia (IH) patients. IH repair in this population may be complex due to an altered anatomical and biological situation as a result of previous procedures and outcomes of IH repair in this population have not been thoroughly assessed. This study aims to assess outcomes of IH repair by dedicated hernia surgeons in patients who have already had two or more re-recurrences., Methods: A propensity score matched analysis was performed using a registry-based, prospective cohort. Patients who underwent IH repair after ≥ 2 re-recurrences operated between 2011 and 2018 and who fulfilled 1 year follow-up visit were included. Patients with similar follow-up who underwent primary IH repair were propensity score matched (1:3) and served as control group. Patient baseline characteristics, surgical and functional outcomes were analyzed and compared between both groups., Results: Seventy-three patients operated on after ≥ 2 IH re-recurrences were matched to 219 patients undergoing primary IH repair. After propensity score matching, no significant differences in patient baseline characteristics were present between groups. The incidence of re-recurrence was similar between groups (≥ 2 re-recurrences: 25% versus control 24%, p = 0.811). The incidence of complications, as well as long-term pain, was similar between both groups., Conclusion: IH repair in patients who have experienced multiple re-recurrences results in outcomes comparable to patients operated for a primary IH with a similar risk profile. Further surgery in patients who have already experienced multiple hernia re-recurrences is justifiable when performed by a dedicated hernia surgeon.

Background: Repair of large ventral hernias with loss of domain can be facilitated by preoperative Botulinum toxin A (BTA) injections and preoperative progressive pneumoperitoneum (PPP). The aim of this study is to evaluate the outcomes of ventral hernioplasty using a standardized algorithm, including component separation techniques, preoperative BTA and PPP., Methods: All patients between June 2014 and August 2018 with giant hernias (either primary or incisional) of more than 12 cm width were treated according to a previously developed standardized algorithm. Retrospective data analysis from a prospectively collected dataset was performed. The primary outcome was closure of the anterior fascia. Secondary outcomes included complications related to the preoperative treatment, postoperative complications, and recurrences., Results: Twenty-three patients were included. Median age was 65 years (range 28-77) and median BMI was 31.4 (range 22.7-38.0 kg/m 2 ). The median loss of domain was 29% (range 12-226%). For the primary and secondary endpoints, 22 patients were analyzed. Primary closure of the anterior fascia was possible in 82% of all patients. After a median follow-up of 19.5 months (range 10-60 months), 3 patients (14%) developed a hernia recurrence and 16 patients (73%) developed 23 surgical site occurrences, most of which were surgical site infections (54.5%)., Conclusion: Our algorithm using both anterior or posterior component separation, together with preoperative BTA injections and PPP, achieved an acceptable fascial closure rate. Further studies are needed to explore the individual potential of BTA injections and PPP, and to research whether these methods can prevent the need for component separation, as postoperative wound morbidity remains high in our study.

Introduction: Small bites for the closure of the abdominal wall after midline laparotomy result in significantly less incisional hernias in comparison with large bites. However, fundamental knowledge of underlying biomechanical phenomena remains sparse. The objective of this study was to develop a digital image correlation-based method to compare different suturing techniques in terms of strain pattern after closure of a midline laparotomy in a passive model just after the time of surgery., Methods: A digital image correlation (DIC)-based method was used for the comparison of strain fields on the external surface of the myofascial abdominal wall (skin and subcutaneous fat removed) among six configurations, including an intact linea alba in five post mortem human specimens. The second configuration comprised primary mass closure with small bites (five mm between two consecutive stitches and five mm distance from the incision, 5x5 mm). The third configuration was primary mass closure with large bites (ten mm by ten mm, 10x10 mm). The fourth, fifth and sixth configuration comprised primary mass closure with large bites and the placement of a mesh in onlay position with two different overlaps and the use of glue to simulate the integration of the mesh within the soft tissue., Results: No visible difference was observed between 5x5 and 10x10 mm closure configurations. However, the use of mesh as suture line reinforcement highlighted a stiffer behavior of the midline area for similar intra-abdominal pressure, which was amplified when a larger mesh overlap was used. However, the whole abdominal wall showed quite similar shapes for the various configurations, except for the configuration with mesh reinforcement and the use of glue., Conclusion: Mesh reinforcement incited lower opening tension profiles in the midline area of the abdominal wall. following closure of the linea alba in median laparotomy. The next step should be to investigate the impact of mesh location (e.g. retromuscular) and different time points after surgery., Competing Interests: Declarations of compting interest A. Le Ruyet, Y. Yurtkap, F.P.J. den Hartog, A. Vegleur, F. Turquier, J.F. Lange and G.J. Kleinrensink have nothing to disclose., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The objective of this study was to assess whether a zinc-impregnated polypropylene mesh (ZnMesh) has better antibacterial properties in a contaminated environment compared with a regular polypropylene mesh., Materials and Methods: Thirty-eight Wistar Han rats underwent cecal ligation and puncture to induce peritonitis 24 h before implantation of an intraperitoneal ZnMesh or a regular polypropylene mesh. Primary outcome was the number of colony forming units (CFU) per sample (mesh and abdominal wall). Secondary outcomes were macroscopic (incorporation of mesh, abscesses, and adhesions on mesh surface) and histological (inflammatory cell reaction, mesh-specific parameters, and collagen deposition) parameters. All outcomes were evaluated after 30 and 90 d., Results: After 30 d, no significant difference in CFU per sample was present between the ZnMesh and control groups. After 90 d, a lower number of CFU per sample was present in the ZnMesh group compared with the control group (trypticase soy agar with 5% sheep blood: 0 log 10 CFU/sample IQR: 0-1.40 versus 1.58 log 10  CFU/sample IQR: 0-4.30, P = 0.012; MacConkey: 0 log 10  CFU/sample IQR: 0-2.65 versus 1.18 log 10  CFU/sample IQR: 0-4.04, P = 0.438). After 90 d, the percentage of adhesions on mesh surface was significantly higher in the ZnMesh group (95% IQR: 60%-100% versus 50% IQR: 23%-75%, P = 0.029). No differences were seen in other macroscopic outcomes or histology., Conclusions: A significantly lower number of CFU per sample was found in the ZnMesh group after 90 d. After 30 d, no statistically significant differences in CFU per sample were seen. This result suggests that the ZnMesh group has better antibacterial properties in a contaminated environment. However, this is at the cost of a significantly higher percentage of adhesions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Incarceration of primary and incisional hernias often results in emergency surgery. The objective of this study was to evaluate the relation of defect size and location with incarceration. Secondary objectives comprised identification of additional patient factors associated with an incarcerated hernia., Methods: A registry-based prospective study was performed of all consecutive patients undergoing hernia surgery between September 2011 and February 2016. Multivariate logistic regression was performed to identify risk factors for incarceration., Results: In total, 83 (3.5%) of 2352 primary hernias and 79 (3.7%) of 2120 incisional hernias had a non-reducible incarceration. For primary hernias, a defect width of 3-4 cm compared to defects of 0-1 cm was significantly associated with an incarcerated hernia (OR 2.85, 95% CI 1.57-5.18, p = 0.0006). For incisional hernias, a defect width of 3-4 cm compared to defects of 0-2 cm was significantly associated with an incarceration (OR 2.14, 95% CI 1.07-4.31, p = 0.0324). For primary hernias, defects in the peri- and infra-umbilical region portrayed a significantly increased odds for incarceration as compared to supra-umbilical defects (OR 1.98, 95% CI 1.02-3.85, p = 0.043). Additionally, in primary hernias age, BMI, and constipation were associated with incarceration. In incisional hernias age, BMI, female sex, diabetes mellitus and ASA classification were associated with incarceration., Conclusion: For primary and incisional hernias, mainly defects of 3-4 cm were associated with incarceration. For primary hernias, mainly defects located in the peri- and infra-umbilical region were associated with incarceration. Based on patient and hernia characteristics, patients with increased odds for incarceration may be selected and these patients may benefit from elective surgical treatment.