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Introduction: Preoperative botolinum toxin A (BTA) administration to the lateral abdominal wall has been widely used since its introduction for treating complex abdominal wall defects and loss of domain (LOD) hernias. Intraoperative fascial traction (IFT) is an established technique for complex abdominal wall hernias exceeding a width of 10 cm and has also shown auspicious results. We present our single center data including 143 consecutive cases combining both techniques from 2019 to 2023. Aim of the study was to develop an algorithm for a tailored approach for very large and complex ventral abdominal wall hernias. Methods: Consecutive patients treated with preoperative BTA and IFT from August 2019 to December 2023 were identified in our prospectively maintained database and reviewed retrospectively. Metrics included intraoperative findings and short-term (30 days) postoperative outcomes. Results: 143 patients were included in our retrospective analysis. The mean age was 58.9 years and 99% of all patients had an ASA Score of II or III with a mean body mass index of 32.4 kg/m2. The mean intraoperative reduction of fascia-to-fascia after BTA and IFT was 9.81 cm. 14 patients either had a lateral defect or a combination of a midline and lateral hernia. An additional uni- or bilateral transverse abdominis release (TAR) was necessary in 43 cases (30.1%). The overall surgical site occurrence rate (SSO) was 30.1% of which 13.8% were surgical site infections (SSI). Re-operation and SSO rates were significantly higher if an additional TAR was performed (both p = 0.001; α = 0.05). Conclusions: IFT in combination with BTA is a transformative and clinically proven tool in the surgeons' toolbox. It might be an easier, and less invasive alternative to other available techniques in many cases, but it should not be looked at as an ultimate stand-alone method to treat all complex W3 hernias. [ABSTRACT FROM AUTHOR]

Introduction: Traditionally, radical prostatectomy (RP) has been considered a contraindication to minimally invasive inguinal hernia repair. Purpose of this systematic review was to examine the current evidence and outcomes of minimally invasive inguinal hernia repair after RP. Materials and methods: Web of Science, PubMed, and EMBASE data sets were consulted. Laparoscopic transabdominal preperitoneal repair (TAPP), robotic TAPP (r-TAPP), and totally extraperitoneal (TEP) repair were included. Results: Overall, 4655 patients (16 studies) undergoing TAPP, r-TAPP, and TEP inguinal hernia repair after RP were included. The age of the patients ranged from 35 to 85 years. Open (49.1%), laparoscopic (7.4%), and robotic (43.5%) RP were described. Primary unilateral hernia repair was detailed in 96.3% of patients while 2.8% of patients were operated for recurrence. The pooled prevalence of intraoperative complication was 0.7% (95% CI 0.2–3.4%). Bladder injury and epigastric vessels bleeding were reported. The pooled prevalence of conversion to open was 0.8% (95% CI 0.3–1.7%). The estimated pooled prevalence of seroma, hematoma, and surgical site infection was 3.2% (95% CI 1.9–5.9%), 1.7% (95% CI 0.9–3.1%), and 0.3% (95% CI = 0.1–0.9%), respectively. The median follow-up was 18 months (range 8–48). The pooled prevalence of hernia recurrence and chronic pain were 1.1% (95% CI 0.1–3.1%) and 1.9% (95% CI 0.9–4.1%), respectively. Conclusions: Minimally invasive inguinal hernia repair seems feasible, safe, and effective for the treatment of inguinal hernia after RP. Prostatectomy should not be necessarily considered a contraindication to minimally invasive inguinal hernia repair. [ABSTRACT FROM AUTHOR]

Background: Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. Method: A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. Results: Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. Conclusion: The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology. [ABSTRACT FROM AUTHOR]

Background: Resorbable biomaterials have been developed to reduce the amount of foreign material remaining in the body after hernia repair over the long-term. However, on the short-term, these resorbable materials should render acceptable results with regard to complications, infections, and reoperations to be considered for repair. Additionally, the rate of resorption should not be any faster than collagen deposition and maturation; leading to early hernia recurrence. Therefore, the objective of this study was to collect data on the short-term performance of a new resorbable biosynthetic mesh (Phasix™) in patients requiring Ventral Hernia Working Group (VHWG) Grade 3 midline incisional hernia repair.Materials and Methods: A prospective, multi-center, single-arm trial was conducted at surgical departments in 15 hospitals across Europe. Patients aged ≥18, scheduled to undergo elective Ventral Hernia Working Group Grade 3 hernia repair of a hernia larger than 10 cm2 were included. Hernia repair was performed with Phasix™ Mesh in sublay position when achievable. The primary outcome was the rate of surgical site occurrence (SSO), including infections, that required intervention until 3 months after repair.Results: In total, 84 patients were treated with Phasix™ Mesh. Twenty-two patients (26.2%) developed 32 surgical site occurrences. These included 11 surgical site infections, 9 wound dehiscences, 7 seromas, 2 hematomas, 2 skin necroses, and 1 fistula. No significant differences in surgical site occurrence development were found between groups repaired with or without component separation technique, and between clean-contaminated or contaminated wound sites. At three months, there were no hernia recurrences.Conclusion: Phasix™ Mesh demonstrated acceptable postoperative surgical site occurrence rates in patients with a Ventral Hernia Working Group Grade 3 hernia. Longer follow-up is needed to evaluate the recurrence rate and the effects on quality of life. This study is ongoing through 24 months of follow-up. [ABSTRACT FROM AUTHOR]

Background: Inguinal hernia repair belongs to the most frequently performed surgical procedures. Endoscopic techniques like TAPP and TEP have become standard of care together with the conventional open techniques. Especially in endoscopic techniques, there is a confusing amount of different meshes and fixation techniques with impact on perioperative and long-term outcome. We present the first single-center data on the use of titanized extra lightweight meshes and fibrin glue fixation compared to staple fixation regarding long-term outcome, especially chronic pain.Materials and Methods: A clinical trial with retrospective analysis of patient- and procedure-related data and questionnaire-based follow-up of TAPP procedures performed in 2012-2014 was conducted in a specialized hernia center. Standard TAPP technique was used with placement of TiMesh extra light (16 g/m2) and either fibrin glue or staple fixation. Procedure- and patient-related data are compared after propensity score matching regarding perioperative complications and long-term outcome.Results: Of 612 TAPP procedures 372 procedures were included in analysis after propensity score matching. Fibrin glue was used in n = 279 and staple fixation in n = 93 cases. There were significant differences regarding duration of the surgical procedures (p = 0.001) and distribution of mesh size. No differences were noted regarding perioperative complications such as seroma or hematoma formation and need for re-laparoscopy. During a mean follow-up of 32.1 ± 20.6 month with a follow-up rate of 79%, there was no difference in long-term outcome, especially for rate of recurrence (p = 0.112) and development of chronic pain (p = 0.846). The overall rate of recurrence was 3.0% (n = 11), and in 2.4% (n = 9) patients complained of chronic pain.Conclusion: Inguinal hernia repair using extra lightweight titanized meshes and fibrin glue fixation is safe and feasible compared to staple fixation even in large and combined hernia defects, if mesh size is adjusted to size of hernia defect. The rate of chronic pain was extremely low at 2.4%. [ABSTRACT FROM AUTHOR]

Background: A considerable number of patients undergoing incisional hernia repair are on anticoagulant or antiplatelet therapy or have existing coagulopathy which may put them at higher risk for postoperative bleeding complications. Data about the optimal treatment of these patients are sparse. This analysis attempts to determine the rate of postoperative bleeding complications following incisional hernia repair and the consecutive rate of reoperation among patients with coagulopathy or receiving antiplatelet and anticoagulant therapy (higher risk group) compared to patients who do not have a higher risk (normal risk group).Methods: Out of the 43,101 patients documented in the Herniamed Registry who had an incisional hernia repair, 6668 (15.5%) were on anticoagulant or antithrombotic therapy or had existing coagulopathy. The implication of that higher risk profile for onset of postoperative bleeding was investigated in multivariable analysis. Hence, other influential variables were identified.Results: The rate of postoperative bleeding in the higher risk group was 3.9% (n = 261) and significantly higher compared to the normal risk group at 1.6% (n = 564) (OR 2.001 [1.699; 2.356]; p < 0.001). Additionally, male gender, use of drains, larger defect size, open incisional hernia repair, lower BMI, and higher ASA score significantly increased the risk of postoperative bleeding. The rate of reoperations due to postoperative bleeding was significantly increased in the higher risk group compared to the normal risk group (2.4 vs. 1.0%; OR 1.217 [1.071; 1.382]; p = 0.003). Likewise, the postoperative general complication rate (6.04 vs. 3.66%; p < 0.001) as well as the mortality rate (0.46 vs. 0.17%; p < 0.001) were significantly higher in the higher risk group.Conclusions: Patients with anticoagulant or antiplatelet therapy or existing coagulopathy who undergo incisional hernia repair have a significantly higher risk for onset of postoperative bleeding. The risk of bleeding complications and complication-related reoperations seems to be lower after laparoscopic intraperitoneal onlay mesh. [ABSTRACT FROM AUTHOR]

Intraperitoneal repair of incisional hernias using a mesh makes particular demands on the material used. In addition to good integration of the mesh on the parietal side, adhesions to the visceral peritoneum must be avoided. Large-pore, light-weight meshes induce fewer adhesions than heavy-weight polypropylene meshes. Although numerous adhesion-barrier substances for use in combination with a polypropylene mesh have been tested already, mostly in open small animal models, unequivocal benefits have been identified to date in only a few of the experiments. Using the laparoscopic intraperitoneal onlay mesh technique, six pigs were implanted with either a lightweight polypropylene mesh (TiMesh light) or TiMesh plus an adhesion-barrier film made of polylactide (SurgiWrap). After 3 months, the animals underwent a postmortem laparoscopy, and specimens were obtained for planimetric and histologic investigations. No adhesions to intestinal structures were found in any of the animals. Adhesions between the greater omentum and the mesh did not differ significantly between the TiMesh (32%) and SurgiWrap (33.5%) groups. The shrinkage of the mesh’s surface area was comparable between the two groups (18% vs. 21%). Histology showed pronounced inflammatory reaction and bridging of scar tissue between the filaments with the use of SurgiWrap versus TiMesh light without film. However, immunohistochemical investigations examining the partial volume of the inflammatory cells, the proliferation marker Ki67, and the apoptotic index at the interface of the filaments all failed to show any significant differences. To avoid adhesions, it is essential that the acute and chronic inflammatory reaction to the implanted material be as small as possible. This requirement is met specifically by the lightweight polypropylene mesh TiMesh light. The additional application of a slowly absorbable adhesion-barrier film made of polylactide (SurgiWrap) does not appear to confer any further benefit. [ABSTRACT FROM AUTHOR]

An anatomical and physiological reconstruction of the abdominal wall after incisional hernia must include reconstruction of the linea alba to restore the physiological function of the vertebral column and respiration. Against this background, a special reconstruction method employing a mesh, which is performed in our department, is presented. In the period between 1 January 2000 and 1 June 2004, a total of 106 patients with incisional hernias after median laparotomy of the upper and lower abdomen were operated on in our department using this tension-free technique with one or two meshes. We have now evaluated the outcomes after a median follow-up of 25.8 months (6.5–53.3). In one patient (0.9%), the peritoneal sac was inadvertently opened, resulting in injury to the small bowel serosa. Surgical complications were observed in 14 patients (13.2%) after dynamic patchplasty. In seven cases (6.6%), wound healing disorders were seen. Overall, 6 out of 106 (5.5%) patients needed revision surgery. In the follow-up period, 92 patients (follow-up 86.8%) could be contacted and re-examined. Four patients (3.8%) had died. There were four recurrences (4.3%), which had already been repaired, and one chronic seroma, which caused no symptoms and which was detected in ultrasound and computed tomography. In view of the possibility of achieving physiological reconstruction and in the light of a tolerable morbidity rate, dynamic patchplasty is a suitable method for incisional hernias. Long-term results hold out promise of an acceptable low recurrence rate. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "TAPP or TEP? population-based analysis of prospective data on 4,552 patients undergoing endoscopic inguinal hernia repair," by M. Gass and colleagues in the 2012 issue.