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Background and Objectives: Tumors of the abdominal wall are uncommon but diverse. The surgical challenge is double. The tumor must be completely removed and the abdominal wall repaired. Our aim was to describe the indications, techniques, and results of surgery on these tumors in an African context., Methods: Retrospective, multicentric and descriptive study conducted in three West African surgical oncology units. We included all abdominal wall tumors followed up between January 2010 and October 2022. Histological type, size, surgical procedure, and method of abdominal wall repair were considered. Survival was calculated using the Kaplan-Meier method and comparisons of proportions were made using the Student t test., Results: We registered 62 tumors of the abdominal wall and we operated on 41 (66.1%). The mean size of the tumors was 14.3 ± 26 cm. Dermatofibrosarcoma and desmoid tumor were present in 33 and 3 cases respectively. In 31.7% of cases in addition to the tumour, the resections carried away the muscular aponeurotic plane. Parietal resections required the use of a two-sided prosthesis in 6 cases. In 13 cases, we used skin flaps. The resections margins were invaded in 5 cases and revision surgery was performed in all of them. Incisional hernia was noticed in 2 cases. The tumor recurrence rate was 12.2% with an average time of 13 months until occurrence. Overall survival at 3 years was 80%., Conclusions: Surgery is the mainstay of treatment for abdominal wall tumors. It must combine tumor resections and parietal repair. Cancer surgeons need to be trained in abdominal wall repair., (© 2023. The Author(s).)

Introduction: Fascial closure during complex abdominal wall reconstruction (AWR) improves recurrence and wound infection rates. To facilitate fascial closure in massive ventral hernias preoperative Botulinum Toxin A (BTA) injection can be used., Methods: 2:1 propensity-scored matching of patients undergoing AWR with and without BTA was performed based on BMI, defect width, and loss of domain using CT-volumetric analysis., Results: 145 patients without BTA and 75 with BTA were comparable on hernia size (240vs251cm 2 , p = 0.589) and hernia volume (1405vs1672cm 3 , p = 0.243). Patients with BTA had higher wound class (CDC≥3 37%vs13%, p < 0.001). Patients with BTA had a higher fascial closure rate (92%vs81%, p = 0.036), received more components separation (61%vs47%, p = 0.042), lower wound infection rate (12%vs26%,p = 0.019) and comparable recurrence rates (9%vs12%, p = 0.589). Recurrences occurred more often without complete fascial closure compared to patients with (33%vs7%, p < 0.001)., Conclusion: In patients with massive ventral hernias and severe loss of domain, preoperative BTA-injection improves fascial closure rates during AWR., Competing Interests: Declaration of competing interest Eva B Deerenberg has received honorarium for speaking for Medtronic. B Todd Heniford has been awarded education grants and honoraria from W.L. Gore and Allergan. Vedra A Augenstein has received honoraria for speaking for Medtronic, Allergan, Intuitive, Acelity, and W.L. Gore. These involvements did not influence the interpretation of results or drafting of this manuscript. All other authors have no relevant financial or personal relationships to disclose that could influence this work or its conclusions., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias., Methods: Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values)., Results: A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049)., Conclusions: In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.

Purpose: To investigate optimal risk factors, including atrophy of the abdominal rectus muscle (ARM) for postoperative parastomal hernia (PH) in patients who underwent end colostomy at left lower quadrant., Methods: This single-institution retrospective study included 91 patients who underwent end colostomy between April 2004 and December 2015. The surgical and long-term outcomes among patients with or without PH were collected and compared., Results: Altogether, 22 (24.2%) patients had a PH including 15 (68.2%) patients with a simultaneous incisional hernia. Univariate analysis showed that older patients (71 ± 11.9 vs. 64 ± 12.2 years, p = 0.03) and those with higher body mass index (BMI) (23.8 ± 3.8 vs. 20.9 ± 3.3 kg/m 2 , p < 0.001) had a statistically significant relation with having PHs. Relative atrophy of left abdominal rectus muscle was more frequently found in patients with PH (ratio of left side/right side; caudal level and medial side: 0.66 vs. 0.92, p < 0.01, caudal level and lateral side: 0.95 vs. 1.03, p = 0.04). Multivariate analysis revealed that BMI > 25 kg/m 2 [odds ratio (OR) 9.05, 95% confidence interval (CI) 2.06-39.76, p = 0.003] and atrophy of the left lower medial portion of the abdominal rectus muscle (OR 12.85, 95% CI 2.49-66.39, p = 0.002) were independent risk factors for PHs. Neither the laparoscopic approach nor the extraperitoneal route of the colostomy was proven to correlate with a lower rate of PHs., Conclusions: High BMI and atrophic change of ARM were significantly associated with PH development. Surgical techniques for prevention of atrophic change of ARM are expected to reduce the incidence of PHs.

Background: Port site hernias (PSH) are underreported following laparoscopic ventral hernia repair (LVHR). Most occur at the site of laterally placed 10-12-mm ports used to introduce large pieces of mesh. One alternative is to place the large port through the ventral hernia defect; however, there is potential for increased risk of surgical site infection (SSI). This study evaluates the outcomes when introducing mesh through a 10-12-mm port placed through the hernia defect., Methods: This was a retrospective case series of patients who underwent LVHR in three prospective trials from 2014-2017 at one institution. All patients had mesh introduced through a 10-12-mm port placed through the ventral hernia defect. The primary outcome was SSI. Secondary outcomes were hernia occurrences including recurrences and PSH., Results: A total of 315 eligible patients underwent LVHR with a median (range) follow-up of 21 (11-41) months. Many patients were obese (66.9%), recently quit tobacco use (8.8%), or had diabetes (18.9%). Most patients had an incisional hernia (61.2%), and 19.2% were recurrent. Hernias were on average 4.8 ± 3.8 cm in width. Two patients (0.6%) had an SSI. Fourteen patients had a hernia occurrence-13 (4.4%) had a recurrent hernia, and one patient (0.3%) had a PSH., Conclusion: During LVHR, introduction of mesh through a 10-12-mm port placed through the hernia defect is associated with a low risk of SSI and low risk of hernia occurrence. While further studies are needed to confirm these results, mesh can be safely introduced through a port through the defect.

Purpose: This study aimed to accurately evaluate incisional hernias with a new three-dimensional (3D) reconstruction technology, proving surgeons more information for intuitive and accurate judgments about incisional hernia to minimize the perioperative complications and recurrence rate., Method: This was a pilot study using a new technique, 3D reconstruction, based on computed tomography (CT) scans to measure abdominal wall defect, herniary area, herniary volume, abdominal cavity volume, and the volume of transverse, oblique, and recti abdominis in three patients with incisional hernias., Results: The 3D reconstruction technique made automated segmentation of the bony skeleton, skin, outer abdominal wall, vessel, and hernia sac. The hernia sac, abdominal muscles, and their anatomic relationship were clearly illustrated in 3D reconstruction images. Moreover, abdominal cavity volume; herniary diameter, area, and volume; and the volume of transverse, oblique, and recti muscles could be evaluated through 3D reconstruction images. Surgeons can also freely combine, rotate, scale, and move the 3D reconstruction mode, modify the name and transparency of the 3D reconstruction model, and observe the internal structure of the tissue and the size, shape, and location of the lesion from multiple angles for better and accurate judgments., Conclusion: The herniary diameter, area, and volume and the volume of transverse, oblique, and recti abdominis can be accurately calculated through this 3D reconstruction technology. A three-dimensional vision of the abdomen through this technology can objectively and quantitatively evaluate the situation of incisional hernia, providing a more realistic means for diagnosis and treatment of incisional hernias., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The most common technique described for robotic ventral hernia repair (RVHR) is intraperitoneal onlay mesh (IPOM). With the evolution of robotics, advanced techniques including retro rectus mesh reinforcement, and component separation are being popularized. However, these procedures require more dissection, and longer operative times. In this study we reviewed our experience with robotic ventral/incisional hernia repair (RVHR) with hernia defect closure (HDC) and IPOM., Methods: Retrospective chart review and follow-up of 31 consecutive cases of ventral/incisional hernia treated between August 2011 and December 2018. Demographics, operative times, blood loss, length of stay (LOS), hernia size, location, and type, mesh size and type, recurrence, conversion to open ventral hernia repair (OVHR) and complications including bleeding, seroma formation and infection were analyzed., Results: Mean age was 63.9 years old, with median BMI of 31.24 kg/m 2 . Median hernia area was 17 cm 2 . Mean operating time was 142.61 min (SD 59.79). Mean LOS was 1.46 days (range 1-5), with 48% being outpatient, and overnight stay in 32% for pain control. Conversion was necessary in 12.9% cases. Complication rate was 3% for enterotomy. Recurrence was 14.81% after a mean follow-up of 26.96 months. There was significant association of recurrence with COPD history (P = 0.0215) and multiple hernia defects (P = 0.0376)., Conclusion: Our recurrence rate (14.81%) compares favorably to those reported in literature (16.7%) for LVHR with HDC and IPOM. Our experience also indicates that IPOM is associated with satisfactory outcomes, low conversion and complications rates, and short LOS.

Introduction: Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR., Methods: OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables., Results: There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m 2 , age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m 2 , p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm 2 , p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm 3 , p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI., Conclusion: The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.

Background: No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons., Methods: A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed., Results: Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery., Conclusions: Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

Conventional «open» procedures for ventral hernias and diastasis recti are widely known, used everywhere and have a great number of author's improvements related to surgeon's experience, availability of modern information, equipment and materials. K. LeBlanc and W. Booth (1993) reported IPOM-method with non-adhesive coating that is considered a milestone in surgery of anterior abdominal wall and ventral hernia. This technique has gained recognition among surgeons around the world due to its technical simplicity, minimal invasiveness and high reproducibility. However, certain disadvantages of this technique have been shown over the past time that justified advisability of searching for another methods of anterior abdominal wall reinforcement. Thus, E-Milos, LIRA, TESAR, eTEP, REPA, TARM, TARUP techniques are currently available. This review is devoted to technical features of these techniques, their potential advantages and disadvantages.

The laparoscopic treatment of abdominal wall defects is currently a valid alternative to the open technique, given the possibility to significantly reduce the length of hospital stay and, consequently, to allow its carrying out in a day surgery setting. The comparison between the two methods has also been the subject of a Cochrane meta-analysis performed by Sauerland et al. (Cochrane Database Syst Rev 3: CD007781, 2011), which pointed out how, in spite of many clinical trials indicating the superiority of laparoscopy in terms of invasiveness and postoperative pain control, the quality of evidence is low due to the excessive variability among the different series in terms of reported complications. Moreover, what should be the selection criteria of patients fit for laparoscopic treatment in day surgery is not yet defined. This retrospective study considered 94 patients with primary or recurrent incisional wall hernias treated with laparoscopic technique over a 7-year period of time, from 2011 to 2018. The aim was to define the selection criteria for an effective day surgery laparoscopic treatment, considering as outcome the rate of conversion to ordinary hospitalization (discharge > POD1). Discharge > POD 1 was necessary in 15 cases out of 94 (16%). Concerning this outcome, statistically significant risk factors were ASA score > I (p = 0.022), number of hernia orifices > 1 (p = 0.001), recurrent hernias (p = 0.002) and hernia diameter > 10 cm (p < 0.0001). These factors were confirmed by univariate binary logistic analysis. A stepwise model of multivariate analysis showed as determinants for adverse events ASA score > 1 (OR 5.2, 95% CI 1.1-25.6, p = 0.043) and hernias > 10 cm (OR 7.0, 95% CI 1.1-46.4, p = 0.045). This work highlighted some useful criteria for preoperative selection of patients fit for laparoscopic abdominal wall defects repair in a day surgery setting. In particular, criteria related to a favorable clinical outcome were ASA score < II and a hernia diameter < 10 cm.

Introduction: In meta-analyses and systematic reviews, clear advantages have been identified for the sublay versus onlay technique for treatment of incisional hernias. Nonetheless, an expert panel has noted that the onlay mesh location may be useful in certain settings., Materials and Methods: First, unadjusted analysis of data from the Herniamed Registry was performed to compare 6797 sublay operations with 1024 onlay operations for repair of incisional hernias. Then, using propensity score matching to account for the influence of variables age, gender, ASA score, BMI, risk factors, preoperative pain, defect size, and defect localization, 1016 pairs were formed and compared with each other., Results: Unadjusted analysis revealed that the onlay operation was used significantly more often for small defects, lateral defect localization, and in women. After comparing the propensity score-matched pairs, no significant difference was found between the sublay and onlay technique in the outcome criteria intra- and postoperative complications, general complications, complication-related reoperations, pain at rest, pain on exertion, chronic pain requiring treatment, and recurrence on 1-year follow-up. But that was true only for this carefully selected patient collective., Conclusion: In a selected patient collective with small and lateral incisional hernias and with a large proportion of women, outcomes obtained for the onlay and sublay techniques do not differ significantly.

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.

Herniation of the liver through the anterior abdominal wall is a rare post-sternotomy complication. A 32-year-old woman had a 2-week wait referral due to abdominal pain, weight loss and upper abdominal swelling. She was known to have a left adrenal myelolipoma and had a mitral valve replacement 3 years prior to presentation with the postoperative period complicated by sepsis and poor wound healing. She had recently been started on metformin for type 2 diabetes mellitus and she had long-standing lower abdominal symptoms known to the gynaecology team. Investigations revealed hepatic herniation of liver segments II & III through the anterior abdominal wall while there was no underlying malignancy a benign left adrenal myelolipoma was noted., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

There are a number of papers discussing medical and mechanical aspects of ventral hernia management. Despite intensive work on the problem understanding, recurrences of the sickness still happen too often. For that reason, new aspects of the problem must be considered. In this article, a change in the abdominal implant's stiffness is discussed, which is caused by cyclic loading. Such loading influence abdominal implant, for example, while patient is coughing or exercising. For the first time, this stiffness change is quantitatively described for a selected knitted mesh. The influence of mesh stiffness changes on repaired hernia persistence is studied. Then, ex vivo experiments on a repaired hernia model under cyclic pressure loading are performed. Finally, numerical simulations of the experiments are made in which stresses and forces in the system are calculated. The two following cases are considered. In the first case, the mesh has its baseline stiffness, and in the second case, the mesh is preconditioned by former loading; thus, it is stiffened. Reaction forces at the mesh fixation points appear to be approximately twofold higher in the second case than in the first case. That may be a reason for a fixation damage in operated hernia system. The results presented shed new light on the necessary strength of mesh fixation in the abdominal wall. They enlarge the state of the art on laparoscopic hernia management with the use of a synthetic implant. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1400-1409, 2019., (© 2018 Wiley Periodicals, Inc.)

Background: Idiopathic spinal cord herniation (ISCH) is a treatable spinal disease. It is rare and often misdiagnosed, causing a delay in management. The etiology is multifactorial, with one of the causes being duplication of the ventral dura. The spinal cord herniates within this defect and becomes strangulated, causing neurological deficits. We report the duplication of a ventral spinal cord as an important cause of ISCH in our review., Case Description: We present 2 cases of ISCH with duplication of the dura, including their relevant clinical and imaging features. The patients underwent surgical reduction of the herniated spinal cord with enlargement of the defect and placement of a dural substitute ventral to the cord. We have also reported the outcomes of the 2 patients, with an emphasis on the factors predictive of poor outcomes (i.e., long-standing symptoms, a delay in intervention, poor neurological status at presentation, and a thinned out atrophic spinal cord found during surgery). We also reviewed the available data for duplication of the dura with ISCH., Conclusions: Very few asymptomatic patients can be treated conservatively. The surgical outcomes have been favorable for symptomatic patients. Proper exposure, gentle manipulation while reducing the herniated spinal cord, enlargement of the defect, and the use of intraoperative monitoring will help limit the postoperative deficits. Duplication of the ventral dura is an important cause of ISCH. It prevents the formation of an anterior pseudomeningocele after surgery. Owing to the rarity of the disease and the lack of follow-up data with recurrence rates, it has not been possible to form clear guidelines for management., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The objective of this study was to evaluate physical, mechanical, and biological properties of the polydioxanone (PDO) monofilament meshes and polyglycolide (PGA) polyfilament meshes in comparison with Permacol ® implants. In rat experimental model, a 1.5 × 2.0 cm defect in abdominal wall was reconstructed by using the Permacol surgical implant or knitted meshes produced from either PDO monofilament, or PGA multifilament. The implant sites were assessed for the tensile strength and the extents of material resorption, host inflammatory response and host tissue replacement on days 3, 10, 30, or 60 after the surgery. The PDO and PGA meshes were rapidly pervaded by the host connective tissue with elements of skeletal muscle histogenesis. The degree of adhesions was significantly higher in the Permacol group. All of the prostheses underwent resorption, which correlated with gradual decreases in the overall tensile strength of the site and the Col1a1 gene expression level. Elevated expression of Fgf2 gene maintained longer in the PDO group, and the Mmp9 gene expression level in this group was higher than in the other groups. Gene expression levels of inflammatory cytokines were higher in the Permacol group. The foreign body giant cell numbers were lower in the PDO and Permacol groups than in the PGA group. Minimal macrophage infiltration with predominance of M2 cells was observed in the PDO group. Overall, the PDO prosthesis turned out to be significantly better than the PGA or Permacol prostheses by a number of indicators of biocompatibility and efficacy. © 2018 The Authors Journal of Biomedical Materials Research Part B: Applied Biomaterials Published by Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 00B: 000-000, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 652-663, 2019., (© 2018 The Authors Journal of Biomedical Materials Research Part B: Applied Biomaterials Published by Wiley Periodicals, Inc.)

Objective: To define the indication for preventive mesh implantation in patients scheduled for laparotomy., Material and Methods: There were 108 patients divided into the control (52 patients without anterior abdominal wall hernia) and the main (56 patients with ventral hernia) groups., Results: Predominance of collagen type III over type I was observed in patients older 60 years in the main group. The maximum ratio of collagen types I and III was 1.4 in the main group. The minimum number of inter-fiber spaces (n=5) was noted in patients aged 30-40 years. The maximum density of connective tissue was 250 pixels per inch., Conclusion: Analysis of connective tissue structures revealed some important age-related features and markers of connective tissue dysplasia in the main group. An indication for preventive mesh implantation in patients scheduled for laparotomy was determined.

Purpose: Pediatric spigelian hernias are very rare. They are often missed or misdiagnosed. A series of cases with spigelian hernia, presented to a tertiary care center are presented here with emphasis on different anatomy of spigelian hernias with cryptorchidism and those without associated cryptorchidism., Materials and Methods: Over a period of seven years, nine cases of spigelian hernia presented to our tertiary care center. Male:female ratio was 3:1.There was a preponderance of right sided hernias. Three patients had associated cryptorchidism. One patient had associated lumbar hernia. All three patients with cryptorchidism had low spigelian hernia while others had classical spigelian hernia., Conclusion: There is a likelihood of anatomical variation in SH associated with UDT and those without UDT. Understanding this anatomy may help in correct scrotal placement of testis., Type of Study: Prospective Observational., Level of Evidence: 4., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to identify risk factors for an adverse event, i.e. early surgical complication, need for ICU care and readmission, following ventral hernia repair. Our hypothesis was that there is an association between an increased complication rate following ventral hernia repair and specific factors, including hernia size, BMI > 35, concomitant bowel surgery, ASA-class, age, gender and method of hernia repair., Methods: Data from a hernia database with prospectively entered data on 408 patients operated for ventral hernia between 2007 and 2014 at two Swedish university hospitals were analysed. A 3-month follow-up of complications, need for intensive care and readmission, was performed by reviewing the medical records., Results: Eighty-one of 408 patients (20%) had a registered complication. Fifty-eight (14%) of these were classed as Clavien I-IIIa, and in 19 cases a Clavien IIIb-IV complication was reported. Large hernia size was associated with increased risk for early complication. A Kendall Tau test analysis revealed a proportional relationship between hernia size and modified Clavien outcome class (p < 0.001). Morbid obesity, ASA-class, method, hernia recurrence, age and concomitant bowel surgery were not statistically significant predictors of adverse events., Conclusions: Assessment of hernia aperture size is of great importance in the preoperative evaluation of ventral hernia patients to consider risk for post-operative complications. These results suggest a careful attitude when applying watchful waiting concepts and when postponing hernia surgery to achieve weight loss. A delaying attitude may result in increased risk of complications caused by increasing hernia size.

Flank and lumbar hernias are challenging because of their rarity and anatomic location. Several challenges exist when approaching these specific abdominal wall defects, including location, innervation of the lateral abdominal wall musculature, and their proximity to bony landmarks. These hernias are confined by the costal margin, spine, and pelvic brim, which makes closure of the defect, including mesh placement, difficult. This article discusses the anatomy of lumbar and flank hernias, the various etiologies for these hernias, and the procedural steps for open and robotic preperitoneal approaches. The available clinical evidence regarding outcomes for various repair techniques is also reviewed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Despite the importance of defect size, there are no standardized recommendations on how to measure ventral hernias. Our aims were to determine (1) if any significant differences existed between various methods of measuring ventral hernias and (2) the effect of these methods of measurement on selection of mesh size., Method: A prospective study of all patients enrolled in a randomized trial assessing laparoscopic ventral hernia repair at a single institution from 3/2015 to 7/2016 was eligible for inclusion. Abdominal wall hernia defect size was determined by multiplying defect length and width obtained separately using each of five methods: radiographic (CT), intraoperative with abdomen desufflated, intraoperative with abdomen insufflated to 15 mmHg (intra-abdominal aspect), intraoperative with abdomen insufflated to 15 mmHg (extra-abdominal aspect), and clinical. The primary outcome was intraclass correlation between the five different methods of measurement for each patient. Secondary outcome was changes in mesh selection assuming a 5 cm overlap in each direction., Results: Fifty patients met inclusion criteria for assessment. The five different measurement methods had an intraclass correlation for each patient of 0.533 (95% CI 0.373-0.697) (weak correlation) for length; 0.737 (95% CI 0.613-0.844) (moderate correlation) for width; and 0.684 (95% CI 0.544-0.810) (moderate correlation) for area. Different types of measurements affected mesh selection in up to 56% of cases., Conclusion: Among five common methods of measuring abdominal wall hernia defect, sizes are only weakly to moderately correlated. Further studies are needed to determine which method results in optimally sized abdominal wall prostheses and superior ventral hernia repair.

Bowel distension frequently indicates bowel obstruction, which is a common diagnosis in clinical radiology. Typically, symptoms and complaints lead to radiological examinations and the detection of the etiology. Untreated intestinal obstructions can lead to a fatal outcome through cardiac failure due to septic shock. Certain of these cases undergo medicolegal investigations depending on the case history, the condition of the decedent, the location of the finding, or recent visits to medical professionals. Computed tomography (CT) is a recommended method in clinical radiology for the detection of bowel obstruction, which is indicated by bowel distension and further radiological signs (eg, the whirl sign, which indicates a volvulus). Postmortem CT (PMCT) has increased worldwide, but PMCT differs from clinical CT; thus, the question of whether PMCT is also reliable for the detection of bowel obstruction in decedents or is negatively affected by postmortem modifications should be discussed. This study consists of 10 cases displaying radiological signs of bowel obstruction. Apart from bowel distension, the most common radiological signs (whirl sign, coffee bean sign, bird beak sign, and u-shape sign) are described and depicted. All decedents underwent autopsy and had a postmortem interval of less than 72 hours. Based on these cases, we assess the reliability of PMCT for detecting bowel obstruction and determining its relationship to the cause of death.

Background: The abdominal wall is frequently manipulated in a variety of reconstructive procedures, and its anatomy is well described. The authors' clinical observations, however, contradict the standard depiction of the components of the abdominal wall at various levels-particularly regarding the course of the transversus abdominis muscle. Therefore, the authors sought to characterize the components of the rectus sheath at various surgical landmarks to define anatomic points important to abdominal wall repair., Methods: The authors analyzed the abdominal computed tomographic studies of 100 healthy, young (age, 18 to 35 years; body mass index, 20 to 40 kg/m) patients with suspected renal calculi. Coordinates of key landmarks were recorded at vertebral levels T12 to L5 using a specially designed computer program that scaled all values and calculated distances between various points., Results: All subjects had significant presence of the transversus abdominis within the rectus sheath (the overlap between the abdominis rectus and transversus abdominis muscles) at the costal margin plane (T12-L1, 4.2 cm). Ninety-nine percent had transversus abdominis presence within the rectus sheath at L1-L2 (3.2 cm), 86 percent at the level of the twelfth rib (L2-L3, 1.4 cm), 36 percent at the umbilicus (L3-L4), and 2 percent slightly above the posterosuperior iliac spine (L5-S1)., Conclusions: These findings contradict classic teachings of abdominal wall structure and highlight the need for a cautious revisiting of the various permutations of component separation, particularly posterior component release. Furthermore, these anatomical landmarks may help predict the development or recurrence of ventral hernias, thus guiding patient selection and informing surgical technique.

Competing Interests: Competing interests: None declared.

Spigelian hernias are rare hernias, occurring through a defect in the Spigelian aponeurosis. Like other hernias, they may contain abdominal contents but are more likely to be incarcerated due to the small size of the fascial defect. Multiple intra-abdominal organs have reportedly been found in Spigelian hernias. A search of the literature showed only nine reported cases in which an appendix has been found within a Spigelian hernia. We present a patient with a history of lower abdominal pain since 10 weeks with a large intra-abdominal mass in the right iliac fossa. Due to abscess formation with spontaneous evacuation through the abdominal wall, drainage and incision were performed and the patient was treated with broad-spectrum antibiotics. An explorative laparoscopy after six weeks showed an incarcerated appendix in a Spigelian hernia.

Traumatic abdominal wall hernias due to blunt abdominal trauma in pediatric patients can pose a diagnostic challenge because of spontaneous hernia reduction. Ultrasonography may be superior to computed tomography for this indication in some cases because of the ability to dynamically and repeatedly assess the area of injury. Herniation can be induced or exaggerated via Valsalva maneuvers, which can facilitate its detection during dynamic assessment. We present the case of a 3-year-old boy who sustained blunt abdominal trauma, with a resultant abdominal wall hernia that was diagnosed using point-of-care ultrasound imaging. This hernia was not visualized with computed tomography, and point-of-care ultrasonography expedited admission for operative repair.

Background: Despite a multitude of evidence-based prediction models and risk factors for postoperative complications after ventral hernia repair, estimating a patient's risk of postoperative complications after ventral hernia repair remains challenging. In an attempt to improve the preoperative assessment of complex hernia patients, some studies have examined pulmonary changes after hernia repair hypothesizing that large hernias lead to pulmonary changes and increased pulmonary complication rates. Some studies have described a correlation between hernia volume and pulmonary changes, although none provided compelling evidence to identify hernia volume as a risk factor for pulmonary complications. This study evaluates the relationship between hernia volume and postoperative pulmonary complications using computed tomography (CT)-based volume measurements., Materials and Methods: Analysis of a prospectively maintained database of consecutive complex hernia patients from 2011 to 2014 undergoing endoscopic (ECST) or open component separation technique (CST) for a hernia defect with a minimum width of 6 cm and visual protrusion of the hernia sac ventral of the rectus abdominis muscles in supine position was performed. Hernia volume was calculated using multiple plane reconstruction of a standard abdominal CT-scan. Noted endpoints were pulmonary complications., Results: Thirty-five patients underwent ECST (n = 20) or CST (n = 15) with a median defect volume of 474 cm 3 (range, 114-2086 cm 3 ). Observed complications were pneumonia (n = 4), pulmonary infiltrate (n = 3), aspiration pneumonia (n = 2), and acute respiratory distress syndrome (n = 1). Univariate and multivariate analyses showed that pulmonary complications were associated with "hernia volume" (P = 0.045; 95% CI: 1.008-1.910)., Conclusions: Hernia volume is a promising risk factor for postoperative pulmonary complications and can be calculated using a standard abdominal CT-scan., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Laparoscopic ventral hernia repair is widely used although its clinical indications are often debated. The aim of this study is to describe our surgical experience in order to establish the safety, efficacy, feasibility of laparoscopic ventral hernia repair and to identify the factors that influence the risk of recurrence in a group of patients treated with only one type of prosthetic mesh and by the same surgical team., Materials and Methods: Between January 2007 and December 2016, 512 patients were admitted to the General and Urgent Surgery Unit, with diagnosis of ventral hernia. Of these, 244 were operated laparoscopically and 268 in a traditional open surgery. In 244 patients treated by laparoscopy we always used a composite mesh: 185 Parietex™ Composite mesh (Medtronic-Covidien, Minneapolis, USA), the remaining other with other types of prosthetic mesh. The type and size of surgical defects, features of surgical technique, length of hospital stay, rate of conversion, morbidity, mortality, and rate of recurrence at 5 years follow-up were retrospective analysed on the 185 patients who underwent surgery with Parietex™ Composite mesh., Results: We performed 185 laparoscopic ventral hernia repair with Parietex™ Composite mesh: 108 (58%) for incisional hernias and 77 (42%) for primary abdominal wall hernias. Mean age was 58 years (19-80). The mean size of abdominal defect was 5 cm (1,5-18), mean BMI was 30,4 kg/m 2 (21-47), mean overlap of the mesh was 5 cm (3-6). The mean operative time was 54 min (30-180) and conversion rate was 3,2%. In 61 patients (33%) we performed a transversus abdominis plane block (T.A.P. block) to reduce postoperative pain. The mean length of hospital stay was 5 days (1-26) (2 days, mean value, in patient with preoperative T.A.P. block). The mortality rate was 0%; overall morbidity was 15,6%. At 5-year follow-up we observed 13 (7%) hernia recurrences. The features of patients with recurrence were as follows: mean age 50 years (19-74), mean ASA Score 3 (2-3), mean BMI 31 kg/m 2 (21-44), mean size of hernial defect 7,5 cm (larger diameter), mean overlap 4,5 cm (3-6)., Conclusions: Laparoscopic repair of ventral hernia using composite mesh is an effective and safe procedure particularly suitable in the following cases: median and paramedian defects, diameter of defect between 5 and 15 cm, "swiss cheese" defects, obesity. In our experience the factors related to the patient and the surgical technique that may influence the onset of early or late recurrence as the follows: a defect size >5 cm (W2 of EHS Classification), an overlap of the mesh < 5 cm, a BMI of 30 kg/m 2 or superior and the presence of significant comorbidities (ASA score: 3). Finally, we observed that the T.A.P. Block preoperative procedure can lead to reduced the clinical costs through a lower administration of analgesics used and a lower length of stay., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Doxycycline, a nonspecific metalloproteinase (MMP) inhibitor, has been demonstrated to impact the strength of the polypropylene (PP) mesh-repaired hernia with an increase in the deposition of collagen type 1. The impact of doxycycline with porcine acellular dermal matrices (PADM) is unknown; therefore, we evaluated the impact of doxycycline administration upon hernia repair with PP and PADM mesh., Methods: Sprague-Dawley rats weighing ~400 g underwent laparotomy with creation of a midline ventral hernia. After a 27-day recovery, animals were randomly assigned to four groups of eight and underwent intraperitoneal underlay hernia repair with either PP or PADM. Groups were assigned to daily normal saline (S) or daily doxycycline in normal saline 10 mg/kg (D) via oral gavage for 8 weeks beginning 24 h preoperatively. Animals were euthanized at 8 weeks and underwent tensiometric testing of the abdominal wall and western blot analyses for collagen subtypes and MMPs., Results: Thirty-two animals underwent successful hernia creation and repair with either PADM or PP. At 8 weeks, 15 of 16 PP-implanted animals survived with only 12 of 16 PADM-implanted animals surviving. There were no differences in the mesh to fascial interface tensiometric strength between groups. Densitometric counts in the PADM-D group demonstrated increased collagen type 1 compared to PP-S (PADM-D [1286.5], PADM-S [906.9], PP-S [700.4], p = 0.037) and decreased collagen type 3 compared to PP-S (PADM-D [7446.9], PADM-S [8507.6], PP-S [11,297.1], p = 0.01). MMP-9 levels were increased in PADM-D (PP-S vs. PADM-D, p = 0.04), while MMP-2 levels were similar between PADM-D and PADM-S, respectively., Conclusions: Collagen type 1 deposition at the mesh to fascial interface is enhanced following administration of doxycycline in ventral hernia repairs with porcine acellular dermal matrices. Doxycycline administration may have implications for enhancing hernia repair outcomes using biologic mesh.

Aim: To analyze collagen types ratio in skin and aponeurosis in order to predict postoperative ventral hernias., Material and Methods: The trial included 141 patients for the period 2012-2015. Group I (n=65) of patients without ventral hernias was divided into subgroup AI (primary operation, n=41) and BI (re-operation, n=24). Group II consisted of 76 patients with ventral hernias. We performed histological examination of skin and aponeurosis to define the collagen structure of connective tissue., Results: There were significant differences between collagen type I/III ratio in skin (2.81±0.52 in group I vs. 1.13±0.48 in group II) and aponeurosis (2.69±0.41 vs. 1.09±0.21, respectively, p≤0.05). We revealed strong direct correlation (r=+0.92) between aponeurosis and skin specimens in one group. Collagen type I level was 73.81±2.74% in subgroup AI and 72.03±2.47% in subgroup BI. Collagen type I was predominant (p≤0.05)., Conclusion: In patients with ventral hernias collagen type I/III ratio in skin is 2.54 times lower than in patients without hernias. Significant correlation of collagen types in skin and aponeurosis (r= +0.92) allows to predict the risk of postoperative ventral hernias on basis of skin fragment.

We report a case of a 86-year old woman with Spiegel hernia complicated by occlusion whose diagnosis was based on CT scan. She was examined in the Emergency Surgery Department for brutal onset of pain in the right iliac fossa associated with vomiting. On physical examination the patient was febrile (38.2° C). It showed hard, sensitive and mobile mass located in the right iliac fossa, with respect to both planes. Abdominal CT scan showed a hernia sac with the neck measuring 13 mm in the right iliac fossa, in front of the aponeurosis of the external oblique muscle. It contained fat and a small bowel loop (curved arrow) with two zones of transition giving a double beak-like appearance at the level of the neck. CT scan showed a lack of enhancement of the wall of the loop after administration of contrast material. The diagnosis of strangulated spiegel hernia associated with sign of arterial ischemia of the digestive wall was retained. Surgery was perfomed with simple postoperative management., Competing Interests: Les auteurs ne déclarent aucun conflit d'intérêts.

Background: Ventral hernia repair (VHR) is a commonly performed operation, but analysis of patient outcomes based upon hernia size is lacking. We sought to identify differences in operative repair and post-operative morbidity and mortality after open VHR based on hernia defect size., Methods: Patient and operative data were retrospectively reviewed on all patients undergoing open incisional VHR between January 2008 and February 2015 by a single surgeon at the Johns Hopkins Hospital. Patient variables were described by means for continuous variables and percentages for discrete variables, with differences between groups calculated by Chi-squared analysis., Results: During the study period, 228 patients underwent open VHR during which intraoperative defect size was measured. Patients were split into four groups based upon defect size: less than 200 cm 2 , 200-300 cm 2 , 301-400 cm 2 , and over 400 cm 2 . Patients with large defects were more likely to present with a recurrent hernia (P = 0.007) and trended towards a history of wound infections (P = 0.07). Operative time was significantly longer as defect size increased (P < 0.001). Component separation was most frequently used in patients with defects 200-300 cm 2 in size (P = 0.001), in whom primary closure was most likely to occur. While mesh was used in almost all patients, the specific location (overlay only, underlay only, or overlay with underlay) depended on hernia size (P < 0.001). Mean length of stay increased with defect size (P < 0.001). Larger defect size was associated with increased 30-day morbidity (P = 0.03) but not readmission (P = 0.53), recurrence (P = 0.99), or mortality (P = 0.99)., Conclusion: Hernia defect size affects operative time and surgical technique for repair of a ventral hernia. Larger defect size is associated with increased post-operative morbidity and length of stay but not readmission, recurrence, or mortality. Hernia size greater than 400 cm 2 should not be a limitation to operative repair.

Introduction: Albeit there is decreasing tendency nowadays for stoma construction, if it still happens, parastomal herniation might occur in up to 50% of cases afterwards. One third of the cases requires surgical correction, not rarely as an emergency. The different methods of repair can be quite demanding and the complication rates are high. From 2003 we have started to use specially designed 3-dimensional meshes for the prevention and repair of parastomal hernias., Methods: From 1st of January 2012 to 1st of June 2016 we have used these devices within the framework of a prospective, controlled, randomized study enrolling the patients in preventive and repair arms. Until now mesh was implanted for prevention at the time of the index operation in 38 cases, (control group: 46 cases), and for repair in 14 cases (control group: 18 cases). Recruitment of the patients will end in 2017. The operations were performed by laparoscopic approach in 22 cases and by open approach in 62 cases in the preventive arm, and 6/26 cases in the repair arm respectively. Mean follow up period is 19.2 months in the mesh group and 22.6 months in the non mesh group in the preventive arm, and 25.9/20.4 months in the repair arm respectively., Results: No statistical analysis was used to interpret these interim results in this paper, we intend to analyze our results at the end of the study. At this stage apparently there is no difference between the group of patients in terms of complications in both arms. Parastomal herniation was found in 18 cases (39.1%) in the non mesh group and in 3 cases (7.8%) in the mesh group in the preventive arm. Recurrency was noted in 8 cases (44%) in the non mesh group, and in 1 case (7.1%) in the mesh group in the repair arm., Conclusions: Our results correlate with other studies where mesh insertion was used to prevent and/or repair parastomal hernias. We attribute these results mainly to the special, 3-dimensional design of the meshes used by us. This construction was developed based on understanding the patomechanism of parastomal hernia formation.

Objective This study investigated the use of prosthetic condensed polytetrafluoroethylene (cPTFE) for laparoscopic ventral hernia repair (LVHR) in an outpatient community-hospital setting. Methods Patients underwent LVHR with cPTFE at one of three community hospitals. Primary endpoint was hernia recurrence at 1-year postoperatively. Secondary endpoints included pain, surgical site infection, medical/surgical complications, and patient-reported outcomes. Results This study included 65 females and 52 males, aged 46.6 ± 13.2 years (mean ± SD; range 18-84 years). Mean prosthetic size was 413.8 ± 336.11 cm 2 (range 165-936 cm 2 ). Mean follow-up was 30 months (range 12-46 months). Hernia recurrence rate was 4.3%. Rate of hospitalization in the first postoperative week was 2.6%. Early and late secondary endpoint complication rates were 24.8% and 27.4%, respectively; pain was the most common complication, followed by seroma (8.5%). Conclusions Outpatient LVHR using cPTFE is feasible in community hospitals. Complication rates were similar to previous reports, and the seroma rate was markedly lower.

Purpose:: To investigate whether there is a difference between Marlex(r) and Dynamesh PP-light Marlex(r) meshes, in the abdominal wall defect correction, on rats in contaminated surgical site., Methods:: Twenty-eight Wistar rats were divided into two groups of 14, and four subgroups of seven animals. All subgroups underwent similar surgical procedure. One group received the mesh Marlex(r) and the other Dynamesh PP-light(r) for correction of the defect. Before implanting, the meshes went through a contamination process, on which was used standard solution containing 10 UFC of Escherichia coli. Fragments of the animal's abdominal wall received macroscopic, microscopic and microbiological analysis., Results:: There was no statistical significance in the analysis of macroscopic variables. Accentuated inflammatory process was shown in all subgroups. The foreign body type reaction was mild in all subgroups, except Dynamesh(r)-14, which was moderate with no statistical significance. The microbiological analysis of the meshes was also similar between the subgroups., Conclusion:: There was no difference between the meshes of Marlex(r) and Dynamesh PP-light(r) in the ventral abdominal wall defect correction on rats in contaminated surgical site.

Spiegelian hernia is a rare anterior abdominal wall hernia, described in 1764 by a Hungarian surgeon. It often remains undiagnosed because of its unusual location on the semilunar line, laterally to the rectus muscle. CT presentation is specific. Because of its high risk of strangulation, a surgical management should be proposed, even in case of fortuitous discovery. We present three cases of Spiegelian hernia, two fortuitously discovered and one detected on the occasion of a small bowel incarceration. We also evoke a similar case of eventration on the lunate line requesting the knowledge of the detailed surgical antecedents for diagnosis.

Background: Early identification of serious adverse events following ventral hernia repair (VHR) could result in improved patient outcomes. Establishment of clinical markers that correlate with serious adverse events following VHR would help facilitate a more timely diagnosis of such events. We investigated the clinical utility of postoperative tachycardia to predict serious adverse events in patients undergoing VHR., Methods: Consecutive patients undergoing VHR at the Cleveland Clinic Comprehensive Hernia Center from September 2013 through June 2015 were identified within the Americas Hernia Society Quality Collaborative database. Tachycardia was classified according to frequency and duration. Sustained tachycardia was defined as >8 consecutive hours of tachycardia on any postoperative day. Serious adverse events were defined as cardiac events, venous thromboembolism, infection, bleeding, and anastomotic leak or missed enterotomy. Association between tachycardia class and serious adverse events was investigated using the Pearson χ(2) test., Results: A total of 377 patients underwent VHR during the study period. A total of 119 (31.6%) patients experienced at least 1 episode of tachycardia. There were 26 (6.9%) patients with a serious adverse event. Tachycardia was present in 21 (80.7%) of these patients. Sustained tachycardia had a significant association with serious adverse events (P = .007). The presence of postoperative tachycardia was associated with the occurrence of a serious adverse event, having a positive likelihood ratio of 2.9 (95% confidence interval 2.2-3.7)., Conclusion: Postoperative tachycardia is common following VHR. Nevertheless, sustained tachycardia is associated with a significant risk for serious postoperative adverse events and mandates further investigation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To evaluate the safety and efficacy of transversus abdominis muscle release (TAR) with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients., Background: Posterior component separation via TAR during abdominal wall reconstruction (AWR) continues to gain popularity. Although our early experience with TAR has been promising, long-term outcomes have not been reported., Methods: From December 2006 to December 2014, consecutive patients undergoing open AWR utilizing TAR were identified in our prospectively maintained database and reviewed retrospectively. Main outcome measures included demographics, perioperative details, wound complications, and recurrences., Results: During the study period, 428 consecutive TAR procedures were analyzed. Mean age was 58, with mean body mass index 34.4 kg/m (range 20-65). Major comorbidities included diabetes (21%), chronic obstructive pulmonary disease (12%), and immunosuppression (3%). Mean hernia defect area was 606 cm (range 180-1280) and average mesh size was 1220 cm (range 600-4500). The majority of cases (66%) were clean, 26% were clean-contaminated, and 8% were contaminated. Eighty (18.7%) surgical-site events occurred, of which 39 (9.1%) were surgical-site infections. Three patients required mesh debridement; however, no instances of mesh explantation occurred. Of the 347 (81%) patients with at least 1-year follow-up (mean 31.5 mo), there were 13 (3.7%) recurrences., Conclusions: Complex AWR represents a formidable surgical challenge. In this large series, we demonstrated that posterior component separation via TAR with wide synthetic mesh sublay provides a very durable repair with low morbidity, even in comorbid patients with large defects. We strongly advocate TAR as a robust addition to the armamentarium of reconstructive surgeons.